REGISTRATION FORMS
RABBI ARTHUR SEGAL TOUR AND RETREAT TO ARGENTINA.
(Tour organized through Community Development Partners For The Americas, LLC)
DATES:
Departure: Thursday May 21, 2009
Return: Sunday, May 31, 2009
COSTS:
PRICE: $2,568.00.
Included in price: Rabbi Arthur Segal's spiritual leadership, Two of Rabbi Arthur's books:"The Handbook of Jewish Spiritual Renewal: A Path of Transformation for the Modern Jew" and "A Spiritual and Ethical Compendium to the Torah and Talmud". Domestic round trip air fare Buenos Aires to Bariloche. Two meals a day (breakfast and either lunch or dinner). Lodging in 4 star accommodations. Ground transportation to all group activities. All group tours and activities in Buenos Aires and in Villa La Angostura. Special events. Meetings and workshops.
To submit your registration materials please print this page and mail to CDPA: 203 Rockingstone Ave. Larchmont, NY 10538. USA. Please email confirmation to: CDPA@cdpa-americas.org. Phone: 914-439-7731.
You may also contact Dr. Hune Margulies at hune@martinbuberinstitute.org, 914-439-7731.
INSTRUCTIONS
1. Please sign and return the complete registration forms and your deposit to CDPA 203 Rockingstone Ave. Larchmont, NY 10538.
2. Mail this entire registration and include a deposit check in the amount of $350.00 per person.
3. Attach to this application a photocopy of the picture page of your passport and a copy of your health insurance card, back and front.
Part I: Personal Information
Full Name, title:
email address:
Date of Birth:
Gender :
Occupation:
Home Address:
City: State: Zip code:
Home Phone:
Cell Phone:
Spouse’s email:
Emergency email:
Work Phone:
web site:
Country of Residence:
Place of Birth:
Citizenship:
Passport Number:
Passport Expiration:
Health Insurance Carrier:
Name of insured:
Policy Number:
Work address:
Emergency Contact Name:
Phone Number:
Other questions:
What is your spiritual practice? (if you have one):
Please provide us with a brief explanation as to special circumstances or concerns: (special diets, health issues, disabilities, etc.). Please describe in detail. All information is strictly confidential and it will be used solely for the purpose of arranging for special services as needed.
➢ Do you speak Spanish?
➢ Need Special Diets?
➢ Taking Medications?
➢ Allergies?
➢ Other Health Issues?
➢ Disabilities?
Part II: Financial Information and Instructions:The cost of the program is $2,568.00. Included in price: Rabbi Arthur Segal's spiritual leadership, Two of Rabbi Arthur's books:"The Handbook of Jewish Spiritual Renewal: A Path of Transformation for the Modern Jew" and "A Spiritual and Ethical Compendium to the Torah and Talmud". Domestic round trip air fare Buenos Aires to Bariloche. Two meals a day (breakfast and either lunch or dinner). Lodging in 4 star accommodations. Ground transportation to all group activities. All group tours and activities in Buenos Aires and in Villa La Angostura. Special events. Meetings and workshops.
Method of payment: Check, Money Order, Cash. Make checks payable to: Community Development Partners For the Americas. A deposit in the amount of $350.00 must accompany this application. Deposits and payments must be made within schedule to insure space in the program and to avoid late penalty charges. Optional choices are not included.
Cancellations: Depending on airline, hotels, buses and other supplier’s policies. After receipt of application a voucher for your deposit will be issued and e-mailed to your attention.
Please Make all checks payable to: COMMUNITY DEVELOPMENT PARTNERS FOR THE AMERICAS. 203 Rockingstone Avenue. Larchmont, NY 10538, USA. Tel: 914-833-7787 / 914-439-7731. Email: CDPA@cdpa-americas.org . www.culture-and-ecology.com
Part III
Please read and sign:
Waiver and Release
Release executed on the___day of __________ , 200 __ , by ________________ (the 'Traveler Releasor') , resident of__________________________________________to Rabbi Arthur Segal and CDPA (the 'Releasee').
I, the Releasor, in consideration of my participation in the Rabbi Rabbi Arthur Segal Tour and Retreat to Argentina, May 21-31, 2009, and run and/or operated by the Releasee, waive, release, and discharge the Releasee, Rabbi Arthur Segal and CDPA , its owners, officers, directors, employees, members, agents, assigns, legal representatives and successors, and all business associates and partners involved in the presentation of the above noted activity and each of them their owners, officers and employees, and any other people officially connected with this event from all liability for or by reason of any damage, loss or injury to person and property, even injury resulting in the death of the Releasor, which has been or may be sustained in consequence of the Releasor's participation in the activity described above, and notwithstanding that such damage, loss or injury may have been caused solely or partly by the negligence of the Releasee. I am aware of the risks of participation. I understand that participation in this program is strictly voluntary and I freely choose to participate. I understand that the Releasee does not provide medical coverage for me. I verify that I will be responsible for any medical costs I incur as a result of my participation
Date:
Name of Traveler:
Signature of Traveler
Name of Traveler
Signature of Traveler
