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:

New York 2019

Florida 2019

Ski Trip 2020

Hawaii 2020

East Coast 2020

West Coast 2020 - Bus 1 and Bus 2

Other:

Name you prefer to be called *

Nickname

Your answer

Date of Birth *

The month/day/year you were born

YYYY

Gender *

Male

Female

E-mail Address *

Your personal e-mail

Your answer

What kind of exchange program are you in? *

Rotary

Other:

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

U.S.A.

Canada

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? *

Yes

If yes, please describe

Your answer

Do you take any medication? *

Yes

If yes, please describe

Your answer

Will you bring medication with you? *

Yes

If yes, please describe

Your answer

Do you have any dietary restrictions? *

Yes

If yes, please describe

Your answer

Are you vegetarian? *

Yes

Do you smoke? *

Yes

Can you swim? *

Yes

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

Chicago, IL

Indianapolis, IN

Detroit, MI

Grand Rapids, MI

Marquette, MI

Minneapolis, MN

St. Louis, MO

Madison, Wi

Milwaukee, WI

Traverse City, MI

Wausau, WI

Rhinelander, WI

Green Bay, WI

Reno, NV

Sacramento, CA

Seattle, WA

Wenatchee, WA

Vancouver, BC

Calgary, AB

Toronto, ON

Duluth, MN

Central Wisconsin, WI

Other:

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? *

Yes

We wish you an amazing trip!

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