RESERVATION FORM

(agreement /conditions to participate)

26th Annual Scientific Symposium HUHMA Haiti Conference

and Cultural Activities

See attachment for trip description.

PLEASE PRINT

Last Name & Degree______First Name ______Title______
Birthdate: ______

MAILING ADDRESS______
CITY ______ST______ZIP______
PHONE (H) ______(B) ______

Cell ______FAX______
EMAIL: ______EMAIL: ______

Conference Room and Activities:

5 Days: January 11-15, 2018: $1,00.00 (USD) – Double Occupancy

PREFERENCES: Bed Type:[ ] King [ ] One Double [ ] Two Double;

WHEELCHAIR:[ ] Y;SPECIAL NEEDS:______

CHECK THE ITEMS BELOW & insert totals, insert the LODGING AMOUNT FROM ABOVE, AND INSERT TOTAL PROJECTED PAYMENT BELOW

FINAL TOTAL $1,000.00

REQUIRED PAYMENT PLAN:

(A)DEPOSITof $250.00 ASAP

(B)$250.00 by November 20, 2017

(C)FINAL PAYMENT of $500.00 by December 11, 2017

() I UNDERSTAND & ACCEPT THE ABOVE DESCRIBED REQUIRED PAYMENT PLAN. I ALSO UNDERSTAND THAT LARGER PAYMENTS CAN BE MADE AT ANY TIME.

Signature ______

26th Annual Scientific Symposium HUHMA Haiti Conference

and Cultural Activities

Payments can be processed thru our PayPal Account:

Make checks payable to HUHMA & return to 4000 Mitchellville Road, Suite 302, Bowie, Maryland 20716

I have read thisRESERVATION FORM (AGREEMENT AND CONDITIONS)and I understand & accept the conditions of the trip. I understand that meals provided will include local cuisine. Any known food allergies have been listed above under "Special Needs." I will be kind & considerate to other trip members, the trip leader and assistants.

For my benefit & the benefit of other trip members, I understand that any trip member who disrupts the group may be asked, at the discretion of the group leaders, to leave the group without refund of trip costs. I understand that I am required to follow the established payment plan. I can pay in advance of the plan if I choose. I FURTHER UNDERSTAND that the final payment must be made by December 11, 2017 AND THAT after January 3, 2018 no portion of my deposit is refundable. I further understand that no refund will be given for any unused portion of the trip should I choose to or be asked to leave anytime during the trip.

DISABILITY & MOBILITY STATEMENT: Since this trip involves travel to a foreign country with accessibility standards other than those common in the United States,HUHMA CANNOT GUARANTEEassistance & accessibility for persons with disabilities. A person with disabilities and/or mobility issues is strongly advised to obtain a dedicated traveling companion to provide assistance. A dedicated traveling companion/aide is considered a trip participant and must pay all costs and fees associated with the trip except dues/guest registration or conference registration.I accept this statement governing disability & mobility issues and allergies.

Signature ______Date ______

NOTE: Signature must be as name on your passport

You will need to make your own flight plans.We will make transportation arrangements for pick up at the airport on January 11, 2018. Please notify us of your flight plans.

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