World Pilgrim Global Education Incorporated

PERSONAL INFORMATION

Name (as on your passport)*

Name you like to be called?*

Trip Choice*

Would you like a single room at an extra cost?*

Yes
No

Name of preferred roomate? (or leave blank and we will try and connect you with someone in need of a roomate)

Age*

Gender

Male
Female
Other

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home #

Mobile #

Email*

Country of Citizenship*

Birth Date*

ABOUT YOU

What are your hopes and expectations for this tour? Why would you like to go? Any concerns or worries about this tour?*

Have you ever traveled to this country before?*

Yes
No

MEDICAL INFORMATION

The following information is confidential to the World Pilgrim staff. We ask you to assess your health in light of the demands of this type of travel experience.

Do you have any medical conditions that would be necessary for us to know about? Please list. How might they affect you on this tour?

Do you have any issues with mobility that leaders should be aware of? We are able to take people with some mobility issues on most tours, it is just helpful to have an idea before we go so we can be prepared.

Please specify any dietary restrictions you may have.

Will you assume any and all possible medical costs incurred during the program?*

Yes
No

EMERGENCY CONTACT INFORMATION

In case of illness or emergency, please notify:

Name of emergency contact*

First Last

Daytime Phone for emergency contact*

PERMISSION FORM FOR EMERGENCY MEDICAL TREATMENT and RELEASE OF LIABILITY AGREEMENT

On rare occasions an emergency requiring medical or hospital treatment may develop during a program. In most cases, administration of an anesthetic, treatment or an injury, or operation on an individual cannot be done without consent of the patient. To avoid a potentially dangerous delay in an emergency if you are unable to give your consent, we request that you sign the following permission to ensure necessary medical treatment.

I hereby grant permission to the World Pilgrim staff to authorize the administration of such antibiotics, immunizations, anesthesia, and other medications, and to hospitalize and provide such treatment for myself that they consider appropriate based on the advice they have received. I hereby further waive and release any claim I may have against the World Pilgrim Staff/Program, its employees, sponsors, and representatives in regard to these decisions in the administration of emergency medical treatment as described herein.

I agree to the Emergency Medical Treatment Form in its entirety*

Yes
No

I have applied and intend to participate in a World Pilgrim Programme. I have voluntarily registered for this programme. I understand and I am aware that during the programme in which I participate certain dangers and/or risks may arise. I expressly voluntarily assume all risk of injury, illness, death and property damage or loss that may result from participation in the World Pilgrim programme. I also agree to abide by all applicable rules, regulations and instructions of the World Pilgrim trip while participating in the programme. I may be asked to leave the programme immediately at my own expense if I fail to abide by the programme standards or if my continued participation in the program will adversely affect my health, safety or welfare or the health, safety and welfare of enjoyment of other World Pilgrim programme participants or leaders. I give permission for my name and email address to be added to the World Pilgrim email list that will only be used to send info on World Pilgrim events of the future, and will never be shared with anyone. I give permission for my photo to be taken during the trip and to potentially be used in World Pilgrim promotional material, never specifically naming me in the photo. Cancellation Policy: I understand the cancellation policy. A $500 CAD deposit is required to register. If I cancel out 90 days or more prior to the tour, I will receive a $400 refund minus $100 for administrative costs. If I cancel out of the tour less than 90 days before the tour begins World Pilgrim is unable to return my $500 deposit due to pre-paid expenses for all tours. Final payment of the entire fee is due 60 days before the tour. If I cancel out of the tour 60 days or less before the tour begins, the entire fee is non-refundable. World Pilgrim may be able to offer a partial credit on a future tour as they evaluate their costs/expenditures on my behalf and what World Pilgrim is able to cancel. If World Pilgrim needs to cancel or reschedule a tour I will receive my entire deposit/payment returned. Purchasing cancellation insurance is recommended. I have carefully read this agreement and release form and fully understand its contents. I sign it of my own free will.

I have carefully read this agreement and release form and fully understand its contents. I sign it of my own free will.*

Yes
No

Participant's signature (or Parent / Guardian if participant is under 19)*

Your typed 'signature' is required to submit this form.

First Last

Date*

You must agree to both the Emergency Medical Treatment Permission Form AND the Release of Liability Agreement to submit your registration

Registration Form

PERSONAL INFORMATION

ABOUT YOU

MEDICAL INFORMATION

EMERGENCY CONTACT INFORMATION

PERMISSION FORM FOR EMERGENCY MEDICAL TREATMENT and RELEASE OF LIABILITY AGREEMENT

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