Clone of Mass Eye Ear Palm Beach January 2026

MGB Outreach Program with Indian Health Services 2026
Department Name
Cost Center
TRAVEL ARRANGER INFORMATION (if not the traveler)
Travel Arranger Name

First NameLast Name
Travel Arranger Phone
Area code and number
Travel Arranger Email Address
TRAVELER INFORMATION

The following information is required for TSA compliance, Great Getaways internal records, reservation ticketing, and MGB Risk Management.
Last Name* / First Name* Middle Name
Traveler Mobile Phone Number
Area code and number
Email Address
- Birth Date
  
  MonthDayYear
- Gender (as it appears on your Passport or Government Issued ID)
  Gender must match Government ID
- TSA Pre✔ Known Traveler Number (KTN) GOES
- Redress Control Number (redress number)
- Departure City
  *Please list departure city/airport
- Departure Date and Time
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDateHourMinutesAM/PM Option
- Arrival/Departure City
  *Please list city/airport
- Return Date and Time
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDateHourMinutesAM/PM Option
- Seating Preference, if available
- Accessibility, special needs requirements, air and hotel preferences, and requests?
- Do you need a car rental? Due to terrain, SUV is required.
- Indicate below your car rental loyalty number if applicable.
- Rental Car:
  
  Only days of volunteer service are covered.
  No Enterprise
  In/Out same airport
  Important Car Insurance Note:
  
  You must accept the maximum rental insurance coverage on every option (collision, liability, etc).
  
  Additional drivers must be added at the time of pick-up in order to present a valid Driver's License.
- Do you have Frequent Flyer Numbers?
- FREQUENT FLYER NUMBERS
- American Airlines
  *If you have a frequent flyer account, please list here.
- Delta Airlines
  *If you have a frequent flyer account, please list here.
- JetBlue
  *If you have a frequent flyer account, please list here.
- United Airlines
  *If you have a frequent flyer account, please list here.
- Southwest Airlines
  *If you have a frequent flyer account, please list here.
- Frequent Flyer other
  *If you have a frequent flyer account, please list here.
- Anything else you'd like us to know?
  *Please indicate any other travel needs, details, health concerns or special requests for this trip.
- During the process of providing travel services, Great Getaways may collect, store, and transmit your personally identifiable information such as name, address, contact information, preferences, demographic information, as well as any hotel or travel requests you provide us. This information is necessary for the facilitation of your travel reservation. This information may be shared with other 3rd parties, such as event organizers, planners, affiliated organizations, and travel and lodging providers. Should you wish to manage the information entrusted to Great Getaways, you can by contacting us via mgbtravel@ggatravel.com
  
  Travelers and arrangers are responsible for complying with the travel policy of their MGB Institution, Department, and Grant(s) as well as government rules and regulation
- Click the Box
- Should be Empty:

MGB Outreach Program with Indian Health Services 2026

TRAVEL ARRANGER INFORMATION (if not the traveler)