REGISTRATION FORMS

RABBI SHEFA GOLD'S PILGRIMAGE TO ECUADOR AND THE GALAPAGOS ISLANDS : April 19-29, 2009
(Tour organized through Community Development Partners For The Americas, LLC)

REGISTRATION FORMS

DATES:
Departure: Sunday, April 19, 2009
Return: Wednesday, April 29, 2009



Double Occupancy at the San Jorge Eco Lodge in the mountains near Quito and Campo Duro, in The Galapagos Islands. (single rooms may be available on an optional basis with a price differential). Price includes: lodging for 9 nights in Quito and in the Galapagos Islands, 3 daily meals, round-trip air-fare from Quito to the Galapagos Islands, all transfers and transportation to group activities, all activities lead by Rabbi Shefa Gold, all city tours, all cultural, ecological, spiritual and touring activities.

To submit your registration materials please print this page and mail to CDPA: 203 Rockingstone Ave. Larchmont, NY 10538. USA. email: CDPA@cdpa-americas.org. Phone: 914-439-7731.

You may also contact Rabbi Shefa Gold at shefa@rabbishefagold.com


INSTRUCTIONS

1. Please sign and return the complete registration forms to Hune Margulies, Ph.D., Director, CDPA 203 Rockingstone Ave. Larchmont, NY 10538.
2. Mail this entire registration and include a check for the total cost of the retreat.
3. Attach to this application a photocopy of the picture page of your passport and a copy of your health insurance card, back and front.

Part I: Personal Information

Full Name, title:
email address:
Date of Birth:
Gender :
Occupation:
Home Address:
City: State: Zip code:
Home Phone:
Cell Phone:
Spouse’s email:
Emergency email:
Work Phone:
web site:
Country of Residence:
Place of Birth:
Citizenship:
Passport Number:
Passport Expiration:
Health Insurance Carrier:
Name of insured:
Policy Number:
Work address:
Emergency Contact Name:
Phone Number:

What is your spiritual practice? (if you have one):


Please provide us with a brief explanation as to special circumstances or concerns: (special diets, health issues, disabilities, etc.). Please describe in detail. All information is strictly confidential and it will be used solely for the purpose of arranging for special services as needed.


➢ Do you speak Spanish?

➢ Need Special Diets?

➢ Taking Medications?

➢ Allergies?

➢ Other Health Issues?

➢ Disabilities?




Part II: Financial Information and Instructions:

Double Occupancy at the San Jorge Eco Lodge in the mountains near Quito and at Campo Duro, Isla Isabela, in The Galapagos Islands. (single rooms may be available on an optional basis with a price differential). Price includes: lodging for 9 nights in Quito and in the Galapagos Islands, 3 daily meals, round-trip air-fare from Quito to the Galapagos Islands, all transfers and transportation to group activities, all activities lead by Rabbi Shefa Gold, all city tours, all cultural, ecological, spiritual and touring activities.

Payments: Method of payment: Check, Money Order, Cash. Make checks payable to: Community Development Partners For the Americas. Optional choices are not included.

Cancellations: Depending on airline, hotels, buses and other supplier’s policies. After receipt of application a voucher for your deposit will be issued and e-mailed to your attention.


Please Make all checks payable to: COMMUNITY DEVELOPMENT PARTNERS FOR THE AMERICAS. 203 Rockingstone Avenue. Larchmont, NY 10538, USA. Tel: 914-833-7787 / 914-439-7731. Email: CDPA@cdpa-americas.org . www.culture-and-ecology.com

Part III

Please read and sign:
Waiver and Release

Release executed on the___day of __________ , 200 __ , by ________________ (the 'Traveler Releasor') , resident of__________________________________________to Rabbi Shefa Gold and CDPA (the 'Releasee').

I, the Releasor, in consideration of my participation in the Rabbi Shefa's Pilgrimage April 19-29, 2009, and run and/or operated by the Releasee, waive, release, and discharge the Releasee and CDPA , its owners, officers, directors, employees, members, agents, assigns, legal representatives and successors, and all business associates and partners involved in the presentation of the above noted activity and each of them their owners, officers and employees, and any other people officially connected with this event from all liability for or by reason of any damage, loss or injury to person and property, even injury resulting in the death of the Releasor, which has been or may be sustained in consequence of the Releasor's participation in the activity described above, and notwithstanding that such damage, loss or injury may have been caused solely or partly by the negligence of the Releasee. I am aware of the risks of participation. I understand that participation in this program is strictly voluntary and I freely choose to participate. I understand that the Releasee does not provide medical coverage for me. I verify that I will be responsible for any medical costs I incur as a result of my participation


Date:
Name of Traveler:

Signature of Traveler

Name of Traveler

Signature of Traveler