APPLICATIONS FOR REGISTRATION TO RABBI ALAN LEW'S RETREAT AND TOUR
Tour dates: December 21-28, 2008. Quito, Ecuador.
(Tour Operations through Community Development Partners For The Americas, LLC)
APPLICATION AND REGISTRATION FORMS
DATES:
Departure: Sunday, December 21, 2008 (flight details will be posted shortly)
Return: Sunday, December 28, 2008 (flight details will be posted shortly)
COSTS:
$2,857.00 per person, Double Occupancy (single rooms may be available on an optional basis with a price differential). Price includes international roundtrip airfare (from San francisco and from New York), lodging for 7 nights, 3 full daily meals, all transfers and transportation to group activities, all activities lead by Rabbi Lan Lew, all city tours, and all cultural, ecological, spiritual and touring activities.
To submit your registration please copy, paste and email to us the registration form below. Also please print and mail to us the signed hard copy of the registration forms together with your payment: Email address: CDPA@cdpa-americas.org. Mailing address: Dr. Hune Margulies, 203 Rockingstone Ave. Larchmont, NY 10538. Phone: 914-439-7731.
You may also contact Rabbi Lew at ALANLEW@comcast.net. Please direct all travel related questions to CDPA@cdpa-americas.org or call 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 $300.00 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:
Spouse’s email:
Emergency email:
Work Phone:
web site:
Country of Residence:
Place of Birth:
Citizenship:
Passport Number: Passport Expiration:
Health Insurance Carrier:
Name of insured:
Policy Number:
Work address:
Emergency Contact Name:
Phone Number:
Optional notes about yourself..
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, (Partial Credit Card payments allowed). 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 $2,857.00. Price includes international roundtrip airfare (from San Francisco and from New York), lodging for 7 nights, 3 full daily meals, all transfers and transportation to group activities, all activities lead by Rabbi Alan Lew, all city tours, and all cultural, ecological, spiritual and touring activities. Price does not include airport taxes.
Payments: A non-refundable deposit in the amount of $300.00 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.
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Waiver and Release
Release executed on the___day of __________ , 200 __ , by ________________ (the 'Traveler Releasor') , resident of__________________________________________to Rabbi Alan Lew and CDPA (the 'Releasee').
I, the Releasor, in consideration of my participation in the Rabbi Alan Lew trip to Ecuador, Decemebr 21-28, 2008, 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
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