DISTRICT BUS TRIP 2014

Registration Form

(1 per student)

Name of Student: ______Male Female (circle)

Host Club:______

Club Contact: ______

Home Phone______Office #______Cell #______

Email address: ______

This is to authorize the above named student to participate in the Inbound Bus Trip
May 4th – May 11th, 2014.

The fee of $550.00/CDN or $500.00/US is the responsibility of the student.

Checks should be made payable to “District 5060 Youth Exchange”.

Payment is due by April 5th, 2013 (Naramata weekend). We will also accept cash or credit cards.

You must make arrangements to pickup your student up on May 11th, 2014 at one of the following designated locations:

(a) Kamloops (b) Vernon (c) Kelowna (d) Penticton (e) Oliver (f) Omak (g) Wenatchee

(h) Quincy (i) Yakima

Please send this form to me along with a check for $550.00CDN or $500.00US or filled out below for a credit payment. Your student may bring it to Naramata on April 5th.

Credit Card Information

Robin DeRock Type of credit card: Visa Master Card (circle)
319 Teakwood Lane Name on card:______

Wenatchee, Wa. 98801 USA Card umber:______
email: Expiration date:______
Ph #: (509) 665-3690 Signature:______

Payee on credit cards will reflect:

Harvey, Lister & Webb Incorporated, Certified General Accountants

Medical Insurance and Authorization

Safety is the ultimate goal during our adventure, however, accidents do occur. In the event of an emergency while on the bus trip, please provide the following information to be taken with the student to the nearest medical facility:

Name of Student: ______

Country of Origin: ______

Current host family name: ______

Current host address: ______

Host Home #:______Host Cell #: ______

Host Work #:______

Insurance Company: ______

Policy #: ______

Insurance Company address: ______

Insurance Company Phone#: ______

(a photo copy of the card will suffice)

Host Club: ______

Name/Numbers club contact can be reached in emergency:

______

In the event of an emergency where it is determined that the student cannot continue on the trip, arrangements to have them picked up should be made and since the bus is on a schedule, we cannot delay the trip waiting for the arrival of their transportation back home. I will have a fellow Rotarian stay with them until you get there.

I will be available on my cell phone at all times unless we are out of cell range.

(e.g. Wells Gray Provincial Park).