Women’s Health Symposium Registration Form

Name As It Appears On Your Passport *
Name As It Appears On Your Passport
Date of Birth
Date of Birth
Passport Expiration Date
Passport Expiration Date
Address
Address
Phone 1
Phone 1
Cell Phone
Cell Phone
Emergency Contact Phone
Emergency Contact Phone
Are You A Vegetarian

I agree to pay $ $1,300 for the Women’s Health Symposium and, if desired, an additional $300 for the Travel Extension by July 1, 2019.  This payment includes round trip airfare from JFK to Guayaquil, Ecuador, and all other project expenses excluding 1 evening meal offsite, daily purchases such as water, ice cream, etc. and lunch and supper during the travel extension.

 I understand that once payment is made, it will be non-refundable.  I also understand that AUF now requires that each participant purchase trip cancellation insurance by the registration due date above.  Also, Ecuador requires proof of traveler’s accident and medical insurance.

______________________________ _____________________

Signature Date

______________________________

Printed Name

Checks payable to: ADOPTA UNA FAMILIA Inc.
Mail to: Linda Smith at 136 Whiting Lane – W. Hartford, CT 06119

Or you may pay online at www.auf-ecuador.org/trippayments

If you pay online there is a 3% service charge

 Trip Insurance companies include but are not limited to the following:   
AAA, AIG Travel Guard, Allianz, Insuremytrip.com, Roamright.com, and Travelinsurance.com 

Additional forms, which may be found at www.auf-ecuador.org/forms include:

 ·      Health form

·      Personal Profile

·      Liability Waiver

·      Copy of Traveler’s Insurance

·      Color copy of Passport

·      Color copy of Drivers License

For a downloadable copy of this form, click here