ICAN McGill
McGill School of Social Work
Wilson Hall, Room 113
3506 University Street
H3A 2A7, CANADA
PERSONAL INFORMATION PASSENGER 1
TITLE:Click here to enter text.
GENDER: MALE ☐ FEMALE ☐
LAST NAME:Click here to enter text.
FIRST NAME:Click here to enter text.
PRIMARY PHONE NUMBER:Click here to enter text.
EMAIL:Click here to enter text.
BIRTHDATE (DD/MM/YYYY):Click here to enter text.
BIRTHPLACE:Click here to enter text.
PASSPORT ISSUING AUTHORITY:Click here to enter text.
PASSPORT ISSUE DATE:Click here to enter text.
PASSPORT EXPIRY DATE:Click here to enter text.
EMERGENCY CONTACT: Click here to enter text.
EMERGENCY CONTACT PHONE NUMBER:Click here to enter text.
PERSONAL INFORMATION PASSENGER 2
TITLE:Click here to enter text.
GENDER: MALE☐ FEMALE ☐
LAST NAME:Click here to enter text.
FIRST NAME:Click here to enter text.
PRIMARY PHONE NUMBER:Click here to enter text.
EMAIL:Click here to enter text.
BIRTHDATE (DD/MM/YYYY):Click here to enter text.
BIRTHPLACE:Click here to enter text.
PASSPORT ISSUING AUTHORITY:Click here to enter text.
PASSPORT ISSUE DATE:Click here to enter text.
PASSPORT EXPIRY DATE:Click here to enter text.
EMERGENCY CONTACT: Click here to enter text.
EMERGENCY CONTACT PHONE NUMBER:Click here to enter text.
BILLING INFORMATION
ADDRESS:Click here to enter text.
CITY:Click here to enter text.
STATE/PROVINCE:Click here to enter text.
POSTAL CODE:Click here to enter text.
COUNTRY:Click here to enter text.
CARDHOLDER'S NAME:Click here to enter text.
CARD NUMBER:Click here to enter text.
EXPIRATION DATE:Click here to enter text.
SECURITY CODE:Click here to enter text.
AMOUNT TO CHARGE:
DEPOSIT AMOUNT $600 USD ☐
FULL AMOUNT $3349 USD PER PASSENGER ☐
TOTAL AMOUNT TO CHARGE*: Click here to enter text.
*Please note, this amount includes the cost of a hotel room shared with another person. If you are a single passenger and elect to stay in a room without a roommate, additional rates will apply.
ADDITIONAL INFORMATION
PLEASE LIST BELOW ANY DISABILITIES, DIETARY RESTRICTIONS OR ALLERGIES, INCLUDING KASHRUT LEVEL, VEGETARIAN, VEGAN, GLUTEN-FREE ETC (IF NOT RELEVANT, PLEASE WRITE "NONE")
PASSENGER 1:Click here to enter text.
PASSENGER 2:Click here to enter text.
IF YOU ARE SHARING A ROOM WITH A ROOMMATE, PLEASE PROVIDE THEIR FULL NAME. *NOTE: IN CASE YOU ARE NOT ABLE TO FIND A ROOMMATE, A SINGLE SUPPLEMENT WILL BE ADDED TO YOUR RESERVATION: Click here to enter text.
PLEASE BOOK CONNECTING DOORS WITH:Click here to enter text.
REQUEST ADJOINING ROOM WITH: Click here to enter text.
REQUEST TWIN BEDS: YES☐ NO☐
TERMS AND CONDITIONS
I understand that in order to travel I will need proper travel documents (eg. passport, visa, photo identification) as required for the place(s) I will visit on my tour.
I have checked that the names of the travelers on my invoice exactly correspond to their passports
I have been advised on the importance of purchasing comprehensive travel insurance
I understand that my trip must be cancelled no later than 72 hours prior to departure in order to be eligible for a refund through the Peace of Mind Cancellation Waiver Program (if purchased)
I understand that I am solely responsible for penalties incurred for tickets, international or domestic, due to schedule and/or flight changes
I am aware that some credit card companies charge an international processing fee, but not all do. Please check with your credit card provider to see what international fees you might incur.
PASSENGER 1 NAME: Click here to enter text.
PASSENGER 2 NAME: Click here to enter text.
DATE: Click here to enter text.
Thank you for choosing to join us on the ICAN Middle East Experience! Please send these documents electronically via email to or send hard-copy versions to the following address:
Marisa Samek
ICAN McGill
School of Social Work
Wilson Hall, Room 113
3506 University Street
Montreal, Quebec, Canada H3A 2A7
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