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Central States 2008 Tour Application


									                                           Central States 2009 Tour Application
                                                       June 13 - 27
                                                                                                                      Attach Current
                                                                                                                      Color Photo

1. Check Your Tour Selection: California: _____ East Coast: ______


2. Student Information:
   ___________________________________________        _______________________________________________
              Last Name                                                First Name
   Student E-Mail Address: ______________________________________________

Name you prefer to be called: ____________________ Your Home Country_______________________________

Male____ Female____ (Check One)                 Date of Birth (MM/DD/YYYY): ___________________________

Do you have any Physical or Medical Conditions ____Yes ___No
If answered, “Yes” please explain

Do you require a Special Diet: ______________________ Are you a Vegetarian: ____________________________
List Interests or Talents: ____________________________________________________________________________

Home Country Information: Parents Names: __________________________________________________________

Home Address: ____________________________________________________________________________________

Home Phone: ______________________________________________________________________________________

3. Rotary Club Information:         District: _____________ Town: _________________________________________

  Youth Exchange Officer: _________________________________________________________________________
                                                             PLEASE PRINT
  Address: ______________________________________________________________________________________

  City: _______________________________ State ______________________Zip _____________________________

  Office Phone #: __________________________Home Phone #: _________________________Cell:______________________

   YEO Email Address:_______________________________________

_____________________________________________                   _____________________________________________
         Club YEO Approval Signature                            District Chair and/or Inbound Coordinator signature

District Chair phone number: Home________________________________Cell:_________________________________

Youth Exchange Counselor Name:_______________________________________Home #___________________________Cell #________________________
                                                             2009 Tour Application page 2

Application Acceptance Requirements:
Return Application along with a $100.00 U.S.D. deposit, a Copy of your Medical Authorization Form (Permission for Medical Care and Release of
Medical Records and Liability Form---This is in your original application that your District Inbound Coordinator and YEO of your club should have), a
Recent Color Photo, and Form of Payment to your District Bus Tour Coordinator, who will then forward everything to the Tour Company.

Cancellation Penalties: 80-61 days prior to departure, 25% of Total Tour Cost; 60-31 days prior to departure, 50% of Total Tour Cost; 30 days to
day of departure 100% of Total Tour Cost.

Optional Trip Cancellation Insurance: If you choose to purchase the optional Trip Cancellation Insurance, go to and fill out the
application on line after the final payment is received.

East Coast ~~~~~~~ $1875.00 U.S.D.
California Tours ~~~~ $2075.00 U.S.D.

Payment: Checks and Money Orders (in U.S. Funds), payable to: MARVIN ENTERPRISES, LLC. or Credit Cards (Visa, MasterCard & American Express)
will be accepted. We do not accept wired money. FINAL PAYMENT IS DUE BY MARCH 16, 2009. Any application received after March 17, 2009 will be
only accepted based on availability.

Credit Card Payments:
Credit Card payments need to be included with application, Name and billing address of credit card holder, complete credit card number, expiration
date, and 3 digit security number located on back of credit card, along with a copy of both front and back of the credit card. You will also need to send
back the Credit Card Authorization Form with your application, filled out by Credit Card Holder.

Tour Cost: Based on 4 People Per Room.

Only 48 Students per Tour will be accepted. First Tour requests will be based on Availability and Post Mark Date.

Rules: See attached rules sheet.

I fully understand the information provided to me regarding the bus tour. _______________________________________________
                                                                          Student Signature

Tour Company:                MARVIN ENTERPRISES, LLC
                             Martha Sekema ~ Terri DeBoer
                             12920 North 950 West
                             DeMotte, IN 46310
                             219-987-6881 Office
                             219-987-5304 Fax

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