TOUR BOOKED: __________________________________________ TOUR DATES:________________________________________________

NAME(S)____________________________________________________________________________________________________________               (please print your legal name(s) as it appears on your picture ID or passport)

NAME(S)  PREFERRED ON NAME TAG: FIRST NAME                      LAST NAME

WE HAVE REQUESTED ROOMS BE DOWNSTAIRS, HOWEVER DUE TO CIRCUMSTANCES OUT OF OUR CONTROL, SOME ROOMS MAY BE UPSTAIRS. CAN YOU STAY IN A ROOM UPSTAIRS IF NEEDED? YES OR NO (CIRCLE ONE)

NON SMOKING OR SMOKING ROOM. (CIRCLE ONE PREFERRED)

PLEASE ENTER YOUR AGE GROUP BELOW: EXAMPLE, 65-69 or 70-75, etc.

MALES: AGE GROUP ________ _______ _______          FEMALES: AGE GROUP ________ ________ ________

DO YOU HAVE ANY SPECIAL DATES WE MAY RECOGNIZE DURING THE TOUR?

BIRTHDAY(S)   NAME     MONTH    DAY                   ANNIVERSARY(S)  NAME     MONTH    DAY

LIST YOUR BEST EXPERIENCES ON A MOTORCOACH TOUR:

LIST YOUR WORSE EXPERIENCES ON A MOTORCOACH TOUR: LIST THE REASON(S) YOU SELECTED THIS TOUR:

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IF PAYING BY CREDIT CARD, COMPLETE THE FOllOWING INFORMATION. YOU HAVE PERMISSION TO USE MY CREDIT CARD FOR PAYMENT. AMOUNT AUTHORIZED: $ __________(RECOMMEND PUT TOTAL COST OF TOUR)

CREDIT CARD TYPE ________________                      CREDIT CARD NUMBER __________________________________________

EXPIRATION DATE ________________  3 DIGIT SIGNATURE PANEL CODE ON REVERSE SIDE________

AUTHORIZED SIGNATURE __________________________________           DATE ____________________

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EMERGENCY DATA: THIS INFORMATION WILL BE TREATED AS PRIVATE. WE WILL TAKE THIS DATA ON THE TOUR IN THE EVENT OF AN EMERGENCY. PLEASE LIST THE PERSON(S) TO BE NOTIFIED IN THE EVENT OF AN EMERGENCY WHILE ON THE TOUR:(CONSIDER LISTING YOUR DOCTOR(S»

NAME ADDRESS TELEPHONE NUMBER RELATIONSHIP:

IS ANYONE TAKING ANY SPECIAL MEDICATIONS WE SHOULD BE AWARE OF? IF YES, PLEASE EXPLAIN:

DOES ANYONE HAVE ANY IMPAIRMENTS OR RESTRICTIONS WE SHOULD BE AWARE OF? IF YES, PLEASE EXPLAIN:

NAME_____________________________ ADDRESS_____________________________________________                                                                    (PERSON COMPLETING FORM)

TELEPHONE NUMBER_________________________ DATE COMPLETED______________________________________