CUBANOW.ORG REGISTRATION FORM
(Please print neatly in dark ink or type)
Please phone the office directly if you are having trouble printing this form.
CUBA EDUCATIONAL TOUR
Background Information Necessary for Cuba Visa Required by both Cuban and United States Governments
Please include a copy of the front page of your passport with this form.
Title of program: Cuba Educational Tour led by Dr. John Gilderbloom and organized as a Cuban Research and Education Program.
Dates of Program: December 5 to December 11, 2003
Please print your full name as it appears on your passport:
Passport number: ____________________________________ Exp. Date: _________________
Passport must be valid 6 months after date of return to the United States.
Do you have a preference for a roommate?
Do you have any special dietary needs?
Requested date of arrival in Havana: December 5, 2003
Departure from Havana: December 11, 2003
Mother's Maiden Name: _______________________________________________________
Your Date of Birth: _______________________________________________________
Country & City of Birth: _______________________________________________________
Country of Citizenship: _______________________________________________________
Were you born in Cuba? _____Yes _____No
Non-US Citizen Green Card Number: ___________________________________________
Please provide copy of Green Card.
I will donate a book about planning, architecture, design, or environmentalism to our Cuban hosts as a people-to-people outreach gesture during our visit to Cuba. _____Yes _____No
Please list all Real Estate, Environment, Planning, Neighborhood or other organizations of which you are a member. Please use a separate sheet of paper if necessary.
Our license requires that a short half page resume or biography accompany each Cuba Study Tour participant’s Cuba and USA Visas application. Please submit your bio or resume with this form.
Liability Release Statement for Participants,
Cubanow.org and Marazul Travel
RESPONSIBITY: Cuban Research and Education Programs (Cubanow.org), Sustainable Urban Networks act only as agents for the suppliers of travel conveyance, transport, accommodation or other service and have no responsibility in whole or in part for any delays, delayed departure or arrival, missed carrier connections, loss, death, damage or injury to person or property or accident, mechanical defect, failure or negligence of any nature howsoever caused in connection with any accommodations, transportation or other services or for any substitution of hotels or of common carrier equipment, with or without, notice, or for any additional expenses occasioned thereby passengers and accepts the terms of this contract.
No revisions of the printed itinerary or its included features are anticipated; however, the right is reserved to make any changes, with or without notice, that might become necessary, with the mutual understanding that any additional expenses will be paid by the individual passenger. Baggage is at the owner's risk throughout the trip, unless insured by the passenger. The right is retained to decline to accept or to retain any person as a member of this trip at any time, subject only to the requirement that the portion of the total amount paid which corresponds to the unused services and accommodations be refunded. If the entire program is cancelled for any reason, participants shall have no claim other than for a full refund.
By forwarding payment, the passenger certifies that he/she has no physical, mental or other condition of disability that would create a hazard for himself/herself or other passengers and accepts the terms of this contract. Someone who can and will be totally responsible for providing all required assistance must accompany program participants requiring extraordinary assistance. Any mental or physical constraints must be reported at the time of registration. All tour members are expected to enjoy traveling as part of a group; tolerant of the occasional changes, delays, or minor mishaps that are part of any kind of travel, whether it is group or individual. Smoking is restricted during all group activities such as when individuals are on the bus, waiting in the lobby or at restaurants. While program and tour operator management will do their best to see to the individual needs of travelers, their principal concern must be the welfare of the group as a whole. Individuals that are disruptive of the tour will be asked to leave at their own expense.
The airlines and other transportation companies concerned are not to be held responsible for any act, omission, or events during the time passengers are not on board their conveyances. The passage contract in use, when issued, shall constitute the sole contract between the company(ies) and the passenger and/or purchaser of this trip. Those attending this program must fully participate in all the activities. We cannot allow non-professionals or non-participants to register for this program. Signing this form demonstrates your understanding that you must be a full participant in this trip.
Signature: ___________________________________________ Date: ____________
Witness: ___________________________________________ Date: ____________
Witness Name: __________________________________ (Please Print)
Your passport must be valid for six months after your return to the United States.
CREDIT CARD AUTHORIZATION
Dear Group Participant,
In order to authorize Cubanow.org to charge your credit card for the services indicated, please fill out and return this form to our office at the address listed above or via fax with a photocopy of both sides
of your credit card.
Charges can only be made to the actual traveler's credit card - except for spouses and children. In this
case, we also require a copy of the credit card holder's driver's license or photo i.d.
We will consider charges to a non-family member's credit card only if the credit card holder is traveling
at the same time and sends a signed letter specifically requesting the additional charges.
We reserve the right to refuse to accept charges to any credit card not issued to the traveler.
FIRST NAME: ________________________
M.I.: _______ LAST NAME: _________________________
(Credit card holder - this should be as it appears on your credit card)
BILLING ADDRESS: ___________________________________________________________________
DAYTIME PHONE: (_____)____________________ EVENING PHONE: (_____)____________________
FAX: (_____)___________________ E-MAIL: ______________________________________________
TYPE OF CREDIT CARD: ________VISA ________MASTERCARD
ACCOUNT NUMBER: _____________________________________ EXP. DATE: _______/_______
SIGNATURE: ____________________________________________ DATE: ____________________
AMOUNT AUTHORIZED: $_________________
DATES OF TRAVEL:
Group Programs to Cuba are subject
to the following cancellation charges if you cancel for any reason:
In addition to airline cancellation penalties, all cancellations for any reason are subject to a $100 per person cancellation fee. Cancellation from 90 to 60 days before departure will result in forfeiture of 10% of the trip cost per person; from 60 to 31 days 30% and from 30 to 8 days 50%. Cancellation from 7 days up to the time of departure will result in forfeiture of the entire cost of the trip.
Trip cancellation and baggage insurance is available at www.travelinsure.com.
Above charges do not include cancellation charges imposed by the airlines for any connecting flights to/from your point of departure to Cuba. Nor do they include air tickets from Canadian or other cities to Havana on a non-refundable basis. Cubanow.org accepts no responsibility for the issuance or denial of licenses by the Office of Foreign Assets Control nor for the issuance or denial of visas by Cuba.