INTERNATIONAL EDUCATIONAL TOUR TO RWANDA PARTICIPANT FORM

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Please complete the attached participant form for the Rwanda Tour 2024 with SAMANTHA REYNOLDS of Sam Reynolds LLC.

Email *

First AND Middle Name (as written on your passport) *

Surname (as written on your passport)

Date of Birth (Mo, Day, Yr) *

YYYY

Citizenship

Passport Number

Passport Expiration Date

YYYY

Passport Issuing Country

Phone (Intl Code + Number)

Physical Address:

HEALTH INFORMATION REGARDING PARTICIPANT

Do you have any physical, mental, or other conditions that may interfere with your ability to participate safely in the Tour or in the Ayurveda, Yoga, or Meditation practices we will do there, e.g., pregnancy, diabetes, anemia, knee problems, back pain, asthma, hearing or seeing impairment, heart condition, inactivity, medication, PTSD, claustrophobia, medications, food allergies or sensitivities, etc.? Yes/No Please explain:

Emergency Contact Information

Full Name, relationship

Phone

Address

Are you choosing single or shared accommodation? *

Single Supplement (I'm aware of extra fee)

Shared - I have a companion

Shared - if possible, please match me. I understand a single supplement may apply if I do not have a travel companion.

If you have a travel companion, please share their name:

A copy of your responses will be emailed to the address you provided.

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