COMMUNITY DEVELOPMENT PARTNERS FOR THE AMERICAS.
email CDPA
email CDPA
REGISTRATION FOR SPRING BREAK IN NICARAGUA
MARCH 13-20, 2011
COSTS: $1,877.00. Prices are based on double or triple occupancy Price includes international round trip air fare from NYC to Managua. lodging for 7 nights, 3 daily meals, all program activities, all transfers and transportation to group activities, city tours, cultural events, entertainment, and other included tours and activities.
REGISTRATION INSTRUCTIONS
1. To submit your registration, please print and mail this form to: CDPA, 635 East 14th St. #11G. New York, NY 10009. USA. Phone: 914-439-7731. CDPA@cdpa-americas.org
2. If paying by check or money order, please include your deposit check in the amount of $500.00. Make checks payable to CDPA. You may also pay the deposit by credit card through our secured Google Checkout Buy Now button below.3. Please also include a photocopy of the photo page of your passport.
Part I: PERSONAL INFORMATION
Full Name:
title:
email address:
phone number:
Date of Birth:
Gender :
Occupation:
Home Address:
City: State: Zip code:
country of residence:
Home Phone:
Cell Phone:
Emergency contact email and phone number:
Fax :
Work Phone:
web site:
Country of citizenship:
Place of Birth:
Passport Number and expiration date:
Please let us know your religious affiliation? (if any):
Please provide us with a brief explanation as to special circumstances or concerns: (special diets, health issues, disabilities, etc.). All information is strictly confidential and it will be used solely for the purpose of arranging for special services as needed.
➢ Need Special Diets?
➢ Taking Medications?
➢ Allergies?
➢ Other Health Issues?
➢ Disabilities?
Part II: Financial information:
Method of payment: Credit Card (please see the secured Google Checkout Buy Now button below), Check, Money Order, Cash, Bank to Bank Wire Transfer to the CDPA's Bank Account. Make checks payable to: CDPA. email CDPA
Deadlines: Deposit deadline is January 18, 2010. Balance deadline is February 18, 2011.
WAIVER AND RELEASE
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Please read and sign the following disclosure statement
Waiver and Release
Release executed on the___day of __________ , 200 __ , by ________________ (the 'Traveler Releaser') , resident of__________________________________________to Community Development Partners For The Americas, (CDPA) (the 'Releasee').
I, the Releaser, in consideration of my participation in CDPA's Spring Break Tour to Nicaragua, Spring Break 2011: March 13-20, 2011, 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 Releaser, which has been or may be sustained in consequence of the Releaser’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
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Community Development Partners For The Americas
