Registration Form - Terra North America Tours
The First Step for booking a Terra North America trip
Last Name *
Surname/Last Name as written in your passport
Your answer
First Name *
As written in your passport
Your answer
Available Tours *
The tour you wish to take:
Name you prefer to be called *
Nickname
Your answer
Date of Birth *
The month/day/year you were born
MM
/
DD
/
YYYY
Gender *
E-mail Address *
Your personal e-mail
Your answer
What kind of exchange program are you in? *
Host Country Rotary District Number (if you are in a Rotary exchange program)
4 digits Rotary District Number in USA or Canada
Your answer
Host Country of Exchange *
The Country where your exchange takes place
Host State/Province in USA or Canada *
The State or Province where your exchange takes place in the USA or Canada
Host Country City *
The City where your exchange takes place in the USA or in Canada
Your answer
Cell Phone Number in USA or Canada - (number only no dashes) *
Area code and phone number
Your answer
Host Country Parent's Names *
Host Parent's Names in the USA or Canada
Your answer
Host Country Parent's Phone Number (number only no dashes) *
Host Parent's Phone number in the USA or Canada
Your answer
Host Country District Chairperson's Name (District Chair or Responsible Officer for your exchange) *
Your answer
Host Country District Chairperson's Phone (Number only - no dashes - District Chair or Responsible Officer for your exchange) *
Your answer
Host Country District Chairperson's E-mail Address (District Chair or Responsible Officer for your exchange) *
Your answer
Home Country *
Name of your Country of Origin (in English)
Your answer
Father's/Guardian Name *
Natural Father's/Guardian's Name
Your answer
Mother's/Guardian's Name *
Natural Mother's/Guardian's Name
Your answer
Phone Number *
Your phone number in your home country
Your answer
Parent's/Guardian's E-mail
The e-mail we can use to contact your parent's/guardian's in your home country
Your answer
Medical Insurance Company *
The name of the company that issued your medical insurance
Your answer
Policy ID number *
The number of your insurance policy
Your answer
Are you Allergic to anything? *
If yes, please describe
Your answer
Do you take any medication? *
If yes, please describe
Your answer
Will you bring medication with you? *
If yes, please describe
Your answer
Do you have any dietary restrictions? *
If yes, please describe
Your answer
Are you vegetarian? *
Do you smoke? *
Can you swim? *
Airport you Depart From *
This should be the airport that is listed on your Host Guarantee form if you are a Rotary student, if you are with another exchange program please list the city nearest your host family
Other Important Information about you:
Anything thing else we should know about you?
Your answer
Do you agree with Terra North America Terms and Conditions? *
We wish you an amazing trip!
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