London Community Theatre Trip

Legal Name (must match Passport)

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home phone

Area CodePhone Number

Cell phone

Area CodePhone Number

E-mail

Confirmation Email

Date of birth (for airline tickets)

Do you have a passport valid until at least September 30, 2019?

If yes, upload a copy of the photo page of your passport.

Browse Files

If no, you will need to submit a copy of your new passport no later than Friday, November 30, 2018.

Contact Study Abroad and Outreach for more details on submitting this document.

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

Payment options

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 November 30, 2018?

Special Requests

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

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.

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

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. 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.

London Community Theatre Trip - March 9-17, 2019