(Tour Operations through Community Development Partners For The Americas, LLC)
APPLICATION AND REGISTRATION FORMS
DATES:
December 15-23, 2009
COSTS:
$2,385.00/person- Double Occupancy (single rooms may be available on an optional basis with a price differential). Price includes flight from Lima to Cusco, lodging, 3 daily meals, all transfers and transportation to group activities, all activities lead by Dr. Mileas Neale and Emily Wolf, all city tours, and all cultural, ecological, spiritual and touring activities. To submit your registration materials please copy, paste and email the information below (or print and mail) to our trip organizers: Dr. Hune Margulies at CDPA@cdpa-americas.org. Phone: 914-439-7731.
INSTRUCTIONS
1. Please sign and return this complete application and registration forms via e-mail to CDPA@cdpa-americas.org.
2. Print this entire application, include a check with your deposit in the amount of $250.00 and return to CDPA: 203 Rockingstone Avenue. Larchmont, NY 10538.
3. Attach to this application a photocopy of the picture page of your passport and a copy of your health insurance card, back and front.
Part I: Personal Information
Full Name:
title:
email address:
Date of Birth:
Gender :
Occupation:
Home Address:
City: State: Zip code:
Home Phone:
Cell Phone:
Emergency email:
Fax :
Work Phone:
web site:
Country of Residence:
Place of Birth:
Citizenship:
Passport Number:
Passport Expiration:
Health Insurance Carrier:
Name of insured:
Policy Number:
Optional Questions to get to know you better...
What is your spiritual practice? (if you have one):
Please provide us with a brief explanation as to special circumstances or concerns: (special diets, health issues, disabilities, etc.). Please describe in detail. All information is strictly confidential and it will be used solely for the purpose of arranging for special services as needed. ➢ Do you know Spanish?
➢ Need Special Diets?
➢ Taking Medications?
➢ Allergies?
➢ Other Health Issues?
➢ Disabilities?
Part II: Financial information:
Method of payment: Check, Money Order, Cash. Make checks payable to: Community Development Partners For the Americas, LLC. 203 Rockingstone Avenue. Larchmont, NY 10538. 914-439-7731.
Part III: Instructions:
Total Cost: The cost of the Tour Program is $2,385.00. Double Occupancy (single rooms may be available on an optional basis with a price differential). Price includes flight from Lima to Cusco, lodging, 3 daily meals, all transfers and transportation to group activities, all activities lead by Dr. Mileas Neale and Emily Wolf, all city tours, and all cultural, ecological, spiritual and touring activities. Price does not include airport taxes.
Payments: A deposit in the amount of $250.00 must accompany this application. Deposits and payments must be made within schedule to insure space in the program and to avoid late penalty charges. Optional choices are not included.
Cancellations: Depending on airline, hotels, buses and other supplier’s policies. After receipt of application a voucher for your deposit will be issued and e-mailed.
Please Make all checks payable to: COMMUNITY DEVELOPMENT PARTNERS FOR THE AMERICAS. 203 Rockingstone Avenue. Larchmont, NY 10538, USA. Tel: 914-833-7787 / 914-439-7731. Email: CDPA@cdpa-americas.org . www.culture-and-ecology.com
Waiver and Release
Release executed on the___day of __________ , 200 __ , by ________________ (the 'Traveler Releasor') , resident of__________________________________________to Dr. Mileas Neale and CDPA (the 'Releasee').
I, the Releasor, in consideration of my participation in the Dr. Miles Neale Retreat December 15-23, 2009, and run and/or operated by the Releasee, waive, release, and discharge the Releasee and CDPA , its owners, officers, directors, employees, members, agents, assigns, legal representatives and successors, and all business associates and partners involved in the presentation of the above noted activity and each of them their owners, officers and employees, and any other people officially connected with this event from all liability for or by reason of any damage, loss or injury to person and property, even injury resulting in the death of the Releasor, which has been or may be sustained in consequence of the Releasor's participation in the activity described above, and notwithstanding that such damage, loss or injury may have been caused solely or partly by the negligence of the Releasee. I am aware of the risks of participation. I understand that participation in this program is strictly voluntary and I freely choose to participate. I understand that the Releasee does not provide medical coverage for me. I verify that I will be responsible for any medical costs I incur as a result of my participation
Date:
Name of Traveler:
Signature of Traveler
Name of Traveler
Signature of Traveler
