COSTA RICA JEWISH YOUNG PROFESSIONALS TRIP

July 30- August 7, 2005

Registration Form

Name:           _____________________________

Birth date:      _____________________________

Address:        _____________________________           City:           _________________ 

State:             _________         Zip: ____________            Country:      _________________

Phone:           (H)    __________________         (W)   _________________

Email:            ____________________

 

Emergency Contact Info:

Name:_____________________________       Phone #’s:_________________________

 

Flight Info:

Airline:____________ Flt. #:__________Arrival Date:___________  Arrival Time:________

                                    Flt. #: _________Departure Date: __________ Departure Time: ______

 

Accommodations:

(  ) Double   (  ) Single (  ) Smoker   (  ) Non Smoker  

Roommate Request: ______________________

 

Tours: (tour selections are final and may not be changed)

 

While in San Jose (please select 1 out of 2)

                        (  ) Class IV Whitewater rafting

                        (  ) Class III Whitewater rafting

                        (  ) Poas/Coffee/La Paz Waterfall Tour

 

While at the Beach (please select 2 out of 3)

                        (  ) Snorkeling

                        (  ) Horseback riding

                        (  ) Canopy tour

 

While at the Volcano (please select 1 out of 2)

                        (  ) Hanging Bridges Hike  

                        (  ) Canyoning 

 

Payment: By reserving through The J Connection you get an additional $50 off

                     (  ) Enclosed is my $250.00 deposit for the trip (Balance due June 1, 2005)

                     (  ) Enclosed is my full payment ($1750 by June 1, 2005 $1850 after)

                     (  ) Enclosed is my single supplement full payment ($2300 by June 1, $2400 after) 

 

Charge my: Visa (  )                        Mastercard (  )                    American Express (  )

 

Card Number:               ___________________________                 

Expiration Date:            ________________

 

I've read, understand and agree to abide by all terms and conditions set forth by Adventure Travel, LLC.  I authorize Adventure Travel LLC to charge my card in the amount stated above.

 

 

Signature:________________________                      Date:__________________

 

To reserve a space fax both forms to Jeff @ 781-444-7741 and a member of our team will be in touch