New York Community Theatre Trip

New York Community Theatre Trip - June 9-17, 2018
Legal Name (as on Driver's License)*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone*

Area CodePhone Number
Work phone

Area CodePhone Number
Cell phone*

Area CodePhone Number
E-mail*

Confirmation Email
Date of birth (for airline tickets)
Emergency Contact #1*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Relationship*
Emergency contact #2

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Relationship
Packages & payment
Package options*

Full package $3,585NYC only $3,185
Payment options*

CheckCredit/debit card
Please make checks payable to Western Illinois University. Send payment to:

Kim McDaniel

Office of Study Abroad and Outreach

WIU

1 University Circle

Macomb, IL 61455
Card type
Amount to charge
Credit card number
Expiration date
Security code
Would you like the final payment charged to your credit card on March 30, 2018?

YesNo
Special Requests
Airline requests: Would you like to request specific seating assignments?

YesNo
If yes, please indicate request.
NOTE: Final seating assignments are at the discretion of the airline
Hotel requests: Would you like to request a single room? An additional $600 charge will apply.*

YesNo
If no, is there someone you would like to room with?

YesNo
If yes, who?
Additional requests--Please list any additional requests or physical accommodations we should be aware of
NOTE: Any hotel requests are at the final discretion of the Hotel Edison. They reserve the right to place couples in a room with one bed.
Disclaimer: The Participant acknowledge and agree to accept all responsibility for loss or additional expenses due to delays or other changes in the means of transportation, other services, or sickness, weather, strikes, or other unforeseen causes. The Participant acknowledge and understand that Western Illinois University assumes no liability whatsoever for any loss, damage, destruction, theft or the like to Participant's luggage or personal belongings, and that Participant has retained adequate insurance or has sufficient funds to replace such belongings and will hold Western Illinois University harmless therefrom. Western Illinois University and the Office of Study Abroad and Outreach reserve the right to make changes to the itinerary, with or without notice, that might become necessary.
Should be Empty:

New York Community Theatre Trip - June 9-17, 2018