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Tabor Trip 2024
13
Questions
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1
FULL NAME
*
This field is required.
EXACTLY AS IT APPEARS ON YOUR DRIVER'S LICENSE
First Name
Middle Name
Last Name
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2
SEX
*
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Male
Female
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3
EMAIL
*
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4
PHONE NUMBER
*
This field is required.
Please enter a valid phone number.
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5
DATE OF BIRTH
*
This field is required.
-
Month
Day
Year
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6
KNOWN ALLERGIES/MEDICAL CONDITIONS
THIS TRIP IS PHYSICALLY DEMANDING. PLEASE LET US KNOW OF ANY CONDITIONS THAT MAY BE PERTINENT FOR US TO KNOW DURING OUR TIME TOGETHER.
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7
EMERGENCY CONTACT
*
This field is required.
In case of an emergency, who would you like us to contact?
Name of Emergency Contact Person
Phone Number of Emergency Contact Person
Relationship to Participant
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8
HEALTH INSURANCE INFORMATION
*
This field is required.
In the event of an emergency, we want to be able to get you the medical services you need. Please carefully fill out the information below.
Name of Health Insurance Provider
Policy Number
Name of Primary Care Physician
Phone Number of Primary Care Physician
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9
PAYMENT METHOD
*
This field is required.
PLEASE REMEMBER: THE COST OF YOUR FLIGHT IS
NOT
INCLUDED IN THIS PRICE.
PAY IN FULL RIGHT NOW ($540)
PAY THE DEPOSIT ($200)
START A PAYMENT PLAN ($90 DUE NOW)
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10
PAYMENT
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My Bag
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Great Product Name
$20
Quantity:
1
Size:
Small
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Great Product Name
$20
Quantity:
1
Size:
Small
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Great Product Name
$20
Quantity:
1
Size:
Small
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Great Product Name
$20
Quantity:
1
Size:
Small
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ORDER SUMMARY
Total cost
USD
Tabor Trip - Pay in Full
$
540.00
+
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Tabor Trip - Deposit
$
200.00
+
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Tabor Trip - Payment Plan
$
90.00
+
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Credit Card
First Name
Last Name
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11
GENERAL LIABILITY WAIVER
*
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I understand that I remain legally responsible for any personal actions. I agree on behalf of myself, heirs, successors, and assigns, to hold harmless and defend Echo Community, their officers, directors, agents and staff, chaperones, or representatives associated with the event, arising from or in connection with my attending the event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate Echo Community, their officers, directors, staff, agents, chaperones, or representatives associated with the activity for reasonable attorney fees and expenses arising in connection therewith.
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12
MEDICAL LIABILITY WAIVER
*
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I hereby authorize Echo Community to carry out the wishes I have named (herein) in areas of emergency medical treatment and other cases of illness for myself. This authorization inclusively extends from August 1-6, 2024. I hereby warrant, to the best of my knowledge, I am in good health, and I assume all responsibility for myself. In the event of an emergency, I hereby give permission to transport me to a hospital for emergency medical or surgical treatment. I ask you to advise the person(s) listed as the emergency contact to any further treatment by the hospital or doctor. I assume full financial responsibility for any medical treatment expenses I may incur. I agree to either pay for services upfront, or if Echo Community pays, I agree to be billed and reimburse their expense.
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13
SIGNATURE OF AGREEMENT
*
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By signing below, you agree to all the terms and conditions listed in the above General Liability Waiver and Medical Liability Waiver.
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