Cuba Trip Registration

Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Phone*
Mobile Phone*
Health Information
How is your general state of health?*
Special medical, physical, dietary limitations, or allergies?*
Primary Physician*
Physician's Phone Number*
List all Rx medications (recommended)

Emergency Contacts
List two individuals not traveling with you who you are confident will assume responsibility for you in case of an emergency.
Contact #1 Name*
Contact #1 Address*
Street Address Address Line 2 City State ZIP Code
Contact #1 Phone*
Contact #1 Mobile*
Contact #1 Email*
Contact #1 Relationship to You*
Contact #2 Name*
Contact #2 Address*
Street Address Address Line 2 City State ZIP Code
Contact #2 Phone*
Contact #2 Mobile*
Contact #2 Email*
Contact #2 Relationship to You*

Reservation Form
Outbound Flight
Outbound Flight Date
Date Format: MM slash DD slash YYYY
Destination
Return Flight
Return Flight Date
Date Format: MM slash DD slash YYYY
Category
Agency
License Group Name
US Passport or US Alien Registration Information
Document Number
Expiration Date
Date Format: MM slash DD slash YYYY
Document Type
Other Country Passport Information
Document Number
Expiration Date
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Municipality ZIP / Postal Code Country
Other Required Passenger Information
Date of Birth*
Date Format: MM slash DD slash YYYY
Mother's Maiden Name*
Country of Residence*
Citizenship*
Gender*
OFAC Category
License Number
OFAC Auth Code

EneriVisions serves only to assist in making necessary travel arrangements for its participating members, and in no way represents, or acts as agent for, transportation carriers, hotel, and suppliers of services connected with this tour. Therefore, is not liable for any injury, loss, accident delay or other irregularity which may be caused by the defect of any vehicle or the negligence or default of any company or person engaged in performing any of the services involved. Additionally, responsibility is not accepted for losses or expenses due to sickness, weather, strike, hostilities, wars, natural disasters or other such causes. All services and accommodations are subject to the laws of the country in which they are provided. EneriVisions does not accept liability of any airline cancellation or delay incurred by the purchase of an airline ticket. Baggage and personal effects are the sole responsibility of the owners at all times. EneriVisions reserves the right to make changes in the published itineraries whenever, in its sole judgment, conditions so warrant, or if they deem it necessary for the comfort, convenience or safety of the tour participant.

EneriVisions also reserves the right to decline any person as a participant in the tours, or to require any participants to withdraw from the tour at any time, when such an action is determined by the appropriate EneriVisions staff representative to be in the best interests of the health, safety, and welfare of the tour group, or of the individual participant.

The undersigned has read carefully the schedule of this tour. The undersigned recognizes that there is a moderate level of physical activity involved in the tour and the tour may require participants to walk long distance and climb stairs. The undersigned accepts any risks thereof and the conditions set forth therein. The undersigned agrees t release and hold harmless EneriVisions and any of their offices or representatives from any liability for delays, injuries or death, or loss of damage to his/her property however occurring during any portion of the program.
I certify that I fully understand all of the above, and that the above information is true and correct. Please sign.
Today's Date
Date Format: MM slash DD slash YYYY
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Health Information

Emergency Contacts

Reservation Form

US Passport or US Alien Registration Information

Other Country Passport Information

Other Required Passenger Information

Travel Affidavit

General Licenses