LEGAL NAME (as on passport)______________________________________________ FULL HOME ADDRESS___________________________________________________ HOME PHONE:____________________

DATE OF BIRTH (MM/DD/YEAR):________________________

CITIZENSHIP_______________________ GENDER: M F

E-MAIL ( of Individual Responsible for Payments:) ______________________________________________ Please write the name of the person(s) who is traveling on the check.

CONTACT IN CASE OF AN EMERGENCY. NAME:_______________________________
HOME ADDRESS:_______________________________________________________ HOME PHONE:______________________ CELL PHONE:____________________

If you are not a citizen of Canada please contact the Consulate of each country that you will be visiting to find out about the visas necessary to go there.

DO YOU HAVE ANY ALLERGIES OR REQUIRE SPECIAL MEDICA TION______YES______NO

IF YES, PLEASE EXPLAIN_________________________________________________ DO YOU REQUIRE ANY SPECIAL MEALS?_____________________________________

SIGNA TURE:___________________________________

DATE (MM/DD/YEAR)____________________________