APPLICATION FORM – Trip Overseas

Dear Parent,

The school that your child attends has chosen our agency to organise their trip and we thank them for their trust. The adventure that your child is about to experience will be enriching. This form establishes the rules governing application for this trip. Please read carefully the information written below and forward this completed form to the group leader.

HAND TOBy ____/____/____

Teacher’s name

School name: File number: TE

APPLICATION FOR THE TRIP TO:FROM TO 20____

DEPOSIT AND PAYMENT

I consent that participates in the trip.
full child’s name
I enclosed a check to ______, for the amount of ______$

School’s name deposit

to confirm his/her application.(If you subscribe to an insurance, please add the required amount to the

check)

I also enclose a post-dated check dated ___/____/____for the amount of ______$ to pay the balance.

CANCELLATION POLICY

Should your child cancel, the following policy will apply.

PENALTIES

Between the reception of the deposit and 60 daysprior to departure: 350.00$ non-refundable (the amount of the deposit)

Between 60 and 45 days prior to departure: 50% of the total cost of the package

Less than 45 days prior to departure: 100% of the total cost of the package

INSURANCE

**ATTENTION** If you subscribe to an insurance, please add the required amount to your deposit

and fill out the “Exclusion form related to pre-existing conditions”.

I want to subscribe to the emergency medical careat a cost of: $______(write your initials)

I REFUSE to subscribe to the medical insurance ______(write your initials)

I want to subscribe to the package plus at a cost of: $______(write your initials)

I REFUSE to subscribe to the package plus ______(write your initials)

I want to subscribe to the package plus without emergency medical care:$______(write your initials)

I REFUSE to subscribe to the package plus without medical ______(write your initials)

I want to subscribe to the package plus without cancellation with interruption at a cost of: $______(write your initials)

I REFUSE to subscribe to the package plus without cancellation ______(write your initials)

By refusing the insurance, I free the travel agency from any and all obligations arising from losses or expenses that might be incurred during the trip as a result of this refusal.

REQUIRED DOCUMENTS

By registering your child for this trip, you commit to provide all documents required by the competent governmental authorities.

For the trip that you are registeringyour child for, you must provide:

Valid passport

Certificate of citizenship as well as 2 id including photo

no document required for this trip

If your child does not have the Canadian citizenship, please ask the teacher for information on entrance policy

I HAVE READ AND ACCEPT THE CONDITIONS MENTIONED ON THIS PAGE

SIGNATURE (parent or legal guardian)DATE

Exclusion form

RELATED TO PRE-EXISTING CONDITIONS

In order to be eligible to the insurance, you have to fill in this form:

In the 3-month period preceding the effective date of the coverage (1), has the insured person: consulted a doctor, been hospitalized, received treatments or been advised to do so, been prescribed medicine or changed your dosage, been treated with oxygen at home, been using corticotherapy for lung condition or used nitro-glycerine for a heart condition more than once in a 7-day period in order to relieve chest pain?

YES

NO 

If you have answered YES, specify the condition: ______

This condition will not be covered by the insurance

(1)Effective date of coverage

  1. Emergency medical care: Departure date
  1. Cancellation or Interruption insurance: Date of subscription

IMPORTANT

Regarding the emergency medical care insurance, if the insured person develops health problems between the date on which the insurance was purchased and the departure date, this health problem may not be covered during the trip. Please contact us if such a situation occurs.

CHILD’S NAME: ______

HOME PHONE NUMBER: ______

______

SIGNATURE(Parent or legal guardian) DATE (MM/DD/YYYY)

All rights reserved

VTE | Student Tour • 874 rue Archimède • G6V 7M5 Lévis (Québec) • 1.877.213.2070 • Fax 418.835.3361 •