2018 Exchange Mission: Cuba
Application Form
Email address *
Personal Information
Name (First & Last) *
Your answer
Organization *
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Job Title *
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Address
City, State, Country & Zip Code
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Mobile Phone Number *
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E-mail Address *
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Passport Information
Full Name as it appears on your Passport *
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Passport Number *
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Country your Passport was Issued by *
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Gender
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Birthdate *
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Passport Expiration Date *
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Emergency Contact Information
Name (First & Last) *
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Email
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Mobile Phone Number *
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Relationship to you
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Physician's Information
Name (First & Last)
Your answer
Phone Number
Your answer
Medical Information
Please list all food and/or medical allergies
Your answer
Do you have any medical conditions we should be aware of?
If yes, please specify (answers are confidential and for your safety only)
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Special Requests
i.e., dietary needs, smoking, accessibility etc.
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Terms & Conditions
The price of the Leading Cities Exchange Mission to Cuba includes hotel, entertainment, ground transportation, taxes, programs, gratuities and most meals. Leading Cities reserves the right to limit participation based upon eligibility requirements and space availability. The mission participation fee reflects the cost of goods and services provided and is not tax deductible. Any donations above and beyond the fee are tax-deductible to the extent allowed by law. *
Participant's Initials
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Ticketing: Airfare is NOT included in the Leading Cities Exchange Mission to Cuba payment. Participants are responsible for booking and purchasing their own airfare, baggage charges, airport transfers and all other air travel fees that may apply. *
Participant's Initials
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Cancellation Policy: Once payment is made, it is transferable but non-refundable. *
Participant's Initials
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Travel Insurance: Leading Cities strongly recommends participants purchase travel insurance which provides for reimbursement for trip delay/missed connections, medical expenses resulting from sickness or accident, lost baggage/personal effects, baggage delay, etc. *
Participant's Initials
Your answer
Notice of Risk of Travel to Cuba and Release
I am aware of the risks of travel to Cuba, including risks associated with my safety and security. I hereby grant permission to Leading Cities to help us obtain emergency medical treatment if necessary. With the full understanding of all of the foregoing, as well as any future travel warnings or advisories that may be in effect at the time of travel. I am voluntarily participating in the Exchange Mission to Cuba sponsored by Leading Cities and hereby agree to accept any and all risks of participating in the delegation. In consideration of my participation in the delegation and in consideration of Leading Cities’ efforts to organize and direct the delegation, I, on behalf of myself and my executors, administrators, heirs, and assigns, hereby release Leading Cities and any of their directors, trustees, officers, agents, and employees, from any claims, demands and causes of action for personal injury or death or loss of or damage to personal property arising from or occurring in connection with my participation or the participation of any other person in this trip or arising out of any medical treatment or first aid provided or procured by Leading Cities. I agree that any dispute arising in connection with the foregoing shall be brought in the Commonwealth of Massachusetts.
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Participant's Initials
Your answer
Supplemental Release of Liability for Death, Personal Injury, and Property Damage
I am a participant of the Leading Cities Exchange Mission to Cuba.

I am signing this Release of Liability for Death, Personal Injury, and Property Damage (Release) in which I acknowledge that I am aware of the risks of travel to Cuba, including risks associated with my safety and security while in Cuba.

I am signing this Supplemental Release to reaffirm my execution of the Release in the light of public information available to me as to the risks associated with my safety and security during the Mission. I confirm that my participation in the Mission is with a full understanding of those risks, which I assume and agree to accept.


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Participant's Digital Signature *
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Please remember to book your airfare separately and be sure to apply for your travel visa (US delegates will have visas issued by Leading Cities' partners).
For current information regarding the U.S. State Department’s position regarding travel to Cuba and surrounding areas, please contact them directly: U.S. State Department, Overseas Citizens Services at 2201 C Street NW, Washington, DC 20520, www.travel.state.gov or phone (202) 647-5225.
A copy of your responses will be emailed to the address you provided.
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