The CVHS Bus Trip Registration Form has been revised ...

Registration Form

Complete the information on front and back. (If traveling with spouse, please fill out separate forms.)  Enclose deposit of $95, made payable to CVHS either by personal check or money order.    Mail to:  CVHS Bus Trip 2016, C/o M. Powers, 1301 Roper Avenue, West Point, Georgia  31833

Personal Contact Information:

Name

Mailing Address

City, State, Zip

Home phone

Cell phone(s)

email

In Case of Emergency notify:

(1)  Name                                                                 Relationship

Home phone                                                    Cell phone

(2)  Name                                                                 Relationship

Home phone                                                    Cell phone

(3)  Primary Care Physician

Office phone

Medical Insurance:

Primary         Company:

Group:                                         Policy or ID #:

Secondary     Company:

Group:                                        Policy or ID#:

Medicare       Claim #                                                             Part B?    Yes  /  No

Medicare Advantage Plan   ID #

Medicare Supplement Policy      Company:

Policy or ID#:

Allergies:

Food allergies?   List:

Medication allergies?  List:

Environmental allergies?   List:

Please read carefully and sign the following Participation Agreement:

I understand that after 12/01/15, any payments made by me or on my behalf are subject to forfeiture if I choose not to go on this trip.    I understand that the registration period will remain open until May 1, 2016, unless the trip capacity of 40 paid travelers is reached prior to that date, in which case I will be contacted and given the opportunity to either be placed on a waiting list (in case of cancellations) or have my check returned to me. I understand that I may choose to make installment payments according to the published payment schedule, but failure to pay by the due date(s) may result in cancellation of my reservation and loss of any monies previously paid.  If registering after Dec. 1, 2015, please pay deposit and any payments that were due prior to the time of your registration. I understand that, if it becomes necessary for me to return home while this trip is underway, I will be responsible for any additional travel costs I might incur. I understand that CVHS reserves the right to cancel this trip on or before January 1, 2016, and that I would be reimbursed for any and all payments I had paid prior to cancellation. I understand that unforeseen circumstances may arise and necessitate substitutions or omissions of certain elements of the published trip itinerary.  I grant permission for pictures and images of myself to be taken while a participant on this trip, provided these pictures and images will be used only for CVHS’s promotional purposes. I understand that I assume all of the risks and responsibilities associated with being a participant on CVHS’s motor coach trip of June 18-22, 2016, and thereby hold harmless and indemnify, release and forever discharge the Chattahoochee Valley Historical Society, as well as its Board of Directors, from and against any and all claims, demands and actions or causes of actions on account of or resulting from my participation in the previously cited trip during the period of participation as aforesaid. _____________________________            __________________________       _________                 Print Name                                                      Signature                                        Date