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.