REGISTRATION FORM

Please type or print (Name as it appears on your passport)

Please Circle:

First Name

Last Name

Address

Apt. #

City

State

Zip

Date of Birth

State of Birth

Nationality

Passport Number

Place Issued

Date Issued

Exp.

Daytime Phone

Evening Phone

E-Mail

Roommate

Tour Number

Destination

Frequent Fiyer Number

Special Meal request

Additional needs

HEALTH & DIETARY NEEDS

Allergy to horse serumAllergy to bee stingsAllergy to tetenus shotsAllergies to some foodsEpileptic/SeizuresHeath/Repriratory/Other

If require a special diet. Please list:(If vegetarian, please be specific.)

Are there any other health issues we should know about?

Name of Physician

Physician's emergency number

Physician's address

City

Zip

Health Insurance Company

Policy Number

Blood Type

ACTIVITIES AND INTEREST

Tour Options

1. If you are intersted inextending your tour, please give us details of what you would like to plan

2. Please give the number of days you wishto extend

Future Travel

1. Where are you interested in traveling?

2. Please give dates:

3. Number of adults:

4. Number of children:

5. Type of accomodations:

Please check the areas of interest. Activities do not apply to every destination:

HistoryBird WatchingObserving WildlifeBotanyPhotographyFishingShoppingGeneral Nature StudyStudying Local CulturesHikingOther

EMERGENCY CONTACT

First Name

Last Name

Address

Apt. #

City

State

Zip

Daytime Phone

Evening Phone

DISCLAIMER

Arrangements for the tour have been made by Xodus International Group LLC, the tour operator Xodus International Group LLC. has engaged the services of airlines, hotels, transport and sightseeing companies which are not its employees or agents. All tickets and coupons are issued subject to any and all terms which govern such means of transportation or services as offered and the insurance and acceptance of such tickets and vouchers shall be deemed consent to the further condition that Xodus International Group shall not become liable or responsible for any loss, injury or damage to or in respect of any person or property.

The tour member specifically waives any claims against Xodus International Group LLC. for any damage to or loss of property or injury or death of persons due to any act of negligence of any person rendering services and accommodations set forth in the itinerary or substitution of services which in their sole opinion or in the opinion of the ground operator are dictated by the prevailing circumstances. This is to include a withdrawal of the tour, cancellation of specific members, alterations or accommodations should conditions warrant. All rates are based on tariffs in effect at the time the tour was planned and are subject to change in the event of adjustment therein.

No refund can be made unless agreed to prior to the departure of the tour. Refunds, if any, are limited to the amounts recovered from the hotels and operators of services and are payable only when received. We also resend the right not to accept or continue with a participant who affects the enjoyment or rights of other group members. This agreement is solely between the participant and Xodus International Group LLC.

Travel Insurance

Travel Insurance Company

Phone Number

Date issued

I have elected not to obtain travelrers insurance. Please initial here

I have read and agreed to the above and to the terms, conditions and cancellation penalties