Travelers’ Information Sheet
National Immunization Days –2017
Please answer every question
and send the completed form to
Thank you!
Click on shaded areas and begin typing. Areas will expand as you type.
Your full nameexactly as it appears on your passport:
Profession:
Your date of birth:
Mailing address (line 1):
Mailing address (line 2):
City:
State/Province:
Zip/Postal Code:
Daytime telephone (including area code):
Evening telephone (including area code):
E-mail address:
Are you a Rotarian? Yes No
If yes, Club: District:
Is your Rotary Club or are you personally involved with an East African humanitarian aid or immunization project already? Yes No
Traveling with someone: Yes No
If yes, name of traveling companion:
Single or double room in hotels: Single Double
If double, please name the person you wish to share a room with:
What size NID Team T-shirt shall we order for you?
Further travel and service in Ugandawill be offered after the week-long immunization campaign in Ethiopia. Please check the box here if you wish to receive more information about post-NID travel to Uganda.
A tour of historic sites in Ethiopia will be offered. Please check the box here if you wish to receive more information about the historic tour of Ethiopia following the Ethiopia polio NID.
Do you wish to make your flight arrangements through Ben Abe at the WorldTravelCenter? Yes No
If so, are you using Frequent Flyer Miles? Yes No
What is the expiration date for your passport?
IMPORTANT: Your passport should be valid until at least June 2018. Please check the expiration date. If your passport will expire less than six months after the return date of this trip, you will need to renew your passport before you apply for the necessary visas.
What is your passport number?
Please be aware that this trip is physically and emotionally challenging. The trip leaders must be informed of any medical issues, and medical and evacuation insurance will be mandatory for all travelers with our group. If you have special medical needs, please provide details here.
Emergency contact name:
Relationship to you:
Phone number – daytime:
Phone number – evening:
Comments:
PLEASE NOTE: Payment for in-country expense is due at the time your participation is confirmed. If you plan to travel just to Ethiopia, the cost is $500. For travel to Uganda, the in-country cost for that country is $475.Once you are confirmed for travel this year, please make checks payable to Ethiopia Polio NID and mail them with your hold harmless agreements to this address:
Ethiopia Polio NID
c/o Jan Nutting
2542 Aztec Dr NW
Olympia, WA 98502