CLIENT PROFILE BOOKING FORM by klutzfu58

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									                               REGISTRATION FORM
                       District 5550 Rotary Youth Exchange
                                 Western Adventure
                                       2009
Student Name:___________________________________________________
Hosted by Rotary Club of:__________________________________________

My Counselors Name is: ______________________________
Street Address/Box Number:______________________
City_____________ Prov.______ Postal Code________
Phone Home:______________Work:_______________Email:_____________________
Fax:_______________________


Special Requests: Please list anything that may apply such as food Requirements
(vegetarian, allergies etc.),mobility needs, etc:___________________________________
________________________________________________________________________
    all requests are registered only and never guaranteed

Students must also supply information on their medical insurance:
Insurance Policy Number Held for My Medical Coverage:________________________
Name of Insurance Company for above Medical:________________________________

Instructions:
This registration form should be forwarded directly to the trip organizer at the
information listed below:

The estimated cost will be $1150.00 including meals and all included activities. A final
cost will be supplied before March 1, 2009. A non refundable deposit of $300.00 is
required no later than March 1, 2009. Final Payment is due by May 1, 2009.

Registration forms should be forwarded to:
                              Dave Pollock
                              Box 973
                              Hudson Bay, SK S0E 0Y0
                              Dave.Pollock@Sasktel.net
                              Fax 306 865 2336

Cheques or money orders should be made payable to and forwarded to:
                           Rotary Youth Exchange, District 5550
                           Box 129
                           Falcon Lake, MB R0E 0N0

								
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