Liability Release and Assumption of Risk Agreement

COSTA RICA JEWISH SINGLES TRIP

July 2-10, 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 III Reventazon white water rafting

( ) Poas Volcano Hike/La Paz Waterfall Gardens

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

( ) Snorkeling

( ) Canopy tour

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

( ) Hanging Bridges Hike

( ) Cano Negro Floating Safari

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

( ) Enclosed is my $300.00 deposit for the trip (Balance due 5/2/05)

( ) Enclosed is my full payment ($1750 by 5/2/05, $1850 after)

( ) Enclosed is my single supplement full payment ($2300 by 5/2/05, $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

	COSTA RICA JEWISH SINGLES TRIP *July 2-10, 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 III Reventazon white water rafting ( ) Poas Volcano Hike/La Paz Waterfall Gardens While at the Beach (please select 1 out of 2) ( ) Snorkeling ( ) Canopy tour While at the Volcano (please select 1 our of 2) ( ) Hanging Bridges Hike ( ) Cano Negro Floating Safari Payment: By reserving through The J Connection you get an additional $50 off ( ) Enclosed is my $300.00 deposit for the trip (Balance due 5/2/05) ( ) Enclosed is my full payment ($1750 by 5/2/05, $1850 after) ( ) Enclosed is my single supplement full payment ($2300 by 5/2/05, $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