8/3/2019 National Parks Registration Form

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HARBOR CITY TRAVEL & TOURS

RESERVATION FORMComplete Reservation Form, enclose your deposit and give to:

Dottie in the GPBSC Travel Dept. ~ Contact #724-1338AMERICAs WESTERN FRONTIERS National Parks Tour

August 30 - September 9, 2012

PERSONAL INFORMATION: ** Your name/s MUST be exactly as it appears on your Proof ofCitizenship. Name:_______________________________________________Telephone:(_____)_________________Cell Phone:(_____)_____________Email Address:_________________Birth Date:________________Spouse or Roommates Name:___________________________________Birth Date:________________

Address:_____________________________________________________________________________City:________________________State:______Zip:______________

Summer Address: (if applicable) __________________________________________________________

City:________________________State:______Zip:____________Telephone:(_____)________________

Expected Date of Arrival Back in Florida:____________________

What name would you like on yourName Badge(s):__________________________________________Physical Health/Disabilities: (You must state if you need any type of assistance - if you are in good

general health, please ignore_______________________________________________________________Celebrations: Please state occasion & date if you are having an anniversary or birthday on board:

_____________________________________________________________________________________Citizenship: __________________________________________________________________________

TOUR INFORMATION:

Occupancy: (Circle One) Double Triple Quad Single Bedding: 1 Bed 2 Beds

Smoking: Yes No

Special Requests: ______________________________________________________________________

AIR INFORMATION: (If applicable,Alternate Departure City:_____________________ ) Air Seating Request: Window Aisle Next to Travel Partner Other: _______________________

Airline Special Requests: Wheelchair Assistance Special Meal Other: ______________________Please Note: Air itinerary will not be available until approximately one-two months in advance of our trip.

HARBOR CITY TRAVEL & TOURS

RESERVATION FORMComplete Reservation Form, enclose your deposit and give to:

Dottie in the GPBSC Travel Dept. ~ Contact #724-1338AMERICAs WESTERN FRONTIERS National Parks Tour

August 30 - September 9, 2012

PERSONAL INFORMATION: ** Your name/s MUST be exactly as it appears on your Proof ofCitizenship. Name:_______________________________________________Telephone:(_____)_________________Cell Phone:(_____)_____________Email Address:_________________Birth Date:________________Spouse or Roommates Name:___________________________________Birth Date:________________

Address:_____________________________________________________________________________City:________________________State:______Zip:______________

Summer Address: (if applicable) __________________________________________________________

City:________________________State:______Zip:____________Telephone:(_____)________________

Expected Date of Arrival Back in Florida:____________________

What name would you like on yourName Badge(s):__________________________________________Physical Health/Disabilities: (You must state if you need any type of assistance - if you are in good

general health, please ignore_______________________________________________________________Celebrations:Please state occasion & date if you a re having an anniversary or birthday on board:

_____________________________________________________________________________________Citizenship: __________________________________________________________________________

TOUR INFORMATION:

Occupancy: (Circle One) Double Triple Quad Single Bedding: 1 Bed 2 Beds

Smoking: Yes No

Special Requests: ______________________________________________________________________

AIR INFORMATION: (If applicable,Alternate Departure City:_____________________ ) Air Seating Request: Window Aisle Next to Travel Partner Other: _______________________

Airline Special Requests: Wheelchair Assistance Special Meal Other: ______________________Please Note: Air itinerary will not be available until approximately one-two months in advance of our trip.

8/3/2019 National Parks Registration Form

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NON-REFUNDABLE CANCELLATION/MEDICAL COVERAGE:

Accept________

Decline________

Passenger 1: Name: ___________________________________________________________

Age: ________ Birthdate: ____________State of legal residence: _______________________

Passenger 2: Name: ____________________________________________________________

Age: ________ Birthdate: ____________State of legal residence: _______________________

INFORMATION WAIVER:

Please Sign below, showing that you have read the Terms & Conditions and are also aware ofthe cancellation penalties and administration fees as stated in the brochure, and that you have

been offered insurance, whether you have chosen to accept coverage or not. Reservation cannot

be processed without your signature.

Signature:________________________________________________DATE:______________

EMERGENCY CONTACT INFORMATION:

Name:________________________________Contact Phone:___________________________

Relationship:___________________________PAYMENT INFORMATION:

$500.00 Deposit is due with reservation - Deposit and insurance must be by check -Reservation confirmation/invoice will be mailed after first deposit is received.

Tour Deposit: $____________

Insurance Payment: $____________ (Coverage Amount Selected: ____________)

TOTAL DEPOSIT: $____________

This is a group policy which offers lower rates than individual coverage. InsuranceMUST be purchased at the time of your first deposit. Pre-existing conditions arecovered. Cost is per person and is refundable if the group minimum is notachieved and the trip is cancelled by Harbor City Travel. The followinginformation is required in order to process your insurance policy:

Up to age 59 Age 60 or older

Up to $3,000 $165 $175

Up to $4,000 $240 $260

NON-REFUNDABLE CANCELLATION/MEDICAL COVERAGE:

Accept________

Decline________

Passenger 1: Name: ___________________________________________________________

Age: ________ Birthdate: ____________State of legal residence: _______________________

Passenger 2: Name: ____________________________________________________________

Age: ________ Birthdate: ____________State of legal residence: _______________________

INFORMATION WAIVER:

Please Sign below, showing that you have read the Terms & Conditions and are also aware ofthe cancellation penalties and administration fees as stated in the brochure, and that you have

been offered insurance, whether you have chosen to accept coverage or not. Reservation cannot

be processed without your signature.

Signature:________________________________________________DATE:______________

EMERGENCY CONTACT INFORMATION:

Name:________________________________Contact Phone:___________________________

Relationship:___________________________PAYMENT INFORMATION:

$500.00 Deposit is due with reservation - Deposit and insurance must be by check -Reservation confirmation/invoice will be mailed after first deposit is received.

Tour Deposit: $____________

Insurance Payment: $____________ (Coverage Amount Selected: ____________)

TOTAL DEPOSIT: $____________

This is a group policy which offers lower rates than individual coverage. InsuranceMUST be purchased at the time of your first deposit. Pre-existing conditions arecovered. Cost is per person and is refundable if the group minimum is notachieved and the trip is cancelled by Harbor City Travel. The followinginformation is required in order to process your insurance policy:

Up to age 59 Age 60 or older

Up to $3,000 $165 $175

Up to $4,000 $240 $260