VIEWS: 4 PAGES: 2 POSTED ON: 3/3/2010
Central States 2009 Tour Application June 13 - 27 Attach Current Color Photo Here 1. Check Your Tour Selection: California: _____ East Coast: ______ ONLY TYPE WRITTEN APPLICATIONS WILL BE ACCEPTED 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 www.tripfreetrip.com 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 firstname.lastname@example.org
"Central States 2008 Tour Application"