Covenanter Tour

egistration

Title
Full name (First, MI, Last)
Suffix
Birthdate (mm/dd/yyyy)
Spouse's Name (First, MI, Last)
Spouse's Birthdate (mm/dd/yyyy)
Address 1
Address 2
City
State
Postal Code
Country
Home Phone
Work Phone
Cell Phone
Home Email
Re-enter your email
Work Email
Re-enter your work email
Congregation Name
Denomination
Children's names and birthdates (if traveling with you)
Child's Name	Child's Birthdate (mm/dd/yyyy)





List each family member who has allergies with their corresponding medications
Name	Allergy	Medication







List each family member with the prescription medications they use
Family Member	Medication







List any physical limitations you or a family member have:

I have checked with my medical insurance provider and my provider does cover my/our medical needs while overseas.
Please write out in two or three paragraphs why you/and your family would like to be a part of the Covenanter Tour and what you hope to gain from this experience.

I have read the description of the Tour and I/we am/are able to engage in 2-3 miles of walking each day without difficulty. I also affirm that I have answered all questions on this form completely and to the best of my ability. If my/our medical condition(s) would worsen prior to departure, I will promptly inform the Tour coordinators. I also understand that the approximate cost of the Tour is to be $2200/person and that it does not include the cost of the international airfare, souvenirs, or any medical emergencies while a part of this trip. Any site seeing done apart from the Tour, will be my sole responsibility.
By my initials, I acknowledge this agreement.