Avela Foundation Information Pack AvelaKilimanjaro_Information Pack | Page 11

Booking Form Payment Details Challenge Details Part One: Registration Fee The Avela Foundation: Together to Give Please debit the non-refundable registration fee of Kilimanjaro Trek 2019 Departure Date June 17 2019 Card Type Personal Details MR MRS MS DR Expiry Date OTHER Mastercard MM YY Name on Card First Name Signature Middle *Please note: The registration fee is payable to Inspired Adventures, the travel cost is payable to Inspired Travel and the fundraising amount is payable to the Charity. Last Part Two: Half Travel Balance Address I authorise Inspired Travel to: Town/Suburb State Debit my Card the half travel balance of $1,675 USD Postcode Tel DAY ( ) Tel NIGHT ( ) Immediately, or in six weeks time. THE NON-REFUNDABLE TRAVEL DEPOSIT OF $615 USD IS INCLUDED IN YOUR TOTAL TRAVEL COST. Mobile How did you hear about us? Email DOB D M Web Y charity email word of mouth OTHER: Passport No. On registration, you will be subscribed to our monthly e-newsletter or Nationality I do not wish to subscribe to the monthly newsletter Country Country of Issue Date of issue D M Y Expiry Date D M Y Signature To: Inspired Adventures, Inspired Travel and the Charity, In signing this booking form, I acknowledge that I have read and understood and accept the booking terms and conditions accompanying this booking form and particularly those relating to release and waiver of liability and that I will hold proper travel insurance for the travel. Accommodation Accommodation is based on twin share. Is there anyone you would like to share with? Signature Date Are you interested in a single room? YES NO A single supplement will apply – price on application D M Y Please note: if you are under 18 years of age this form requires the signature of a parent or legal guardian. Please send completed form signed on this page and on the next page email: [email protected] Departure City Do you have a pre-existing medical conditions which may affect your ability to undertake this challenge? YES NO (you will be required to complete a medical risk assessment prior to travel) Do you have any special dietary requests? Twitter Handle @ Emergency Contact Contact Relationship Tel DAY ( ) Tel NIGHT ( ) Mobile VISA Card Number Please write your name as it appears on your passport. Please circle $145 USD* Please note: A 1.5% surcharge is payable on credit card transactions.