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Central Europe Tour Information Form
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* Indicates required question
Email
*
Your email
Student Last Name
*
Your answer
Student First Name
*
Your answer
Personal Email (non mbusdapps account)
*
Your answer
Primary Orchestra Instrument
*
Your answer
Current Grade Level
*
9th
10th
11th
12th
Alumnus
MCHS Orchestra Group (check one group only)
*
Philharmonic Strings
Sinfonietta Strings
Symphony Orchestra (including winds & percussion)
Chamber & Symphony Orchestras
Alumnus (performing with Symphony)
Student Legal Last Name (as it appears on their passport)
*
Your answer
Student Legal First & Middle Name (as it appears on their passport)
*
Your answer
Passport Country of Citizenship
*
USA
Other:
Passport Number
*
Your answer
Passport Date of Issue
*
MM/DD/YYYY
MM
/
DD
/
YYYY
Passport Date of Expiration
*
MM/DD/YYYY
MM
/
DD
/
YYYY
Student Cell Phone Number
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Will the student have international call access during the trip?
*
Yes
No
Will the student be able to receive group text messages on their cell phone during the trip (will have international cell coverage plan for travel within Czechia and Poland)?
*
Yes
No
Will the student be able to receive group text messages on wifi-based apps (e.g. Whatsapp, Groupme)?
*
Yes
No
List any food allergies (write N/A if you have none).
*
Your answer
List any other dietary restrictions (write N/A if you have none).
*
Your answer
List any medication allergies or other non-food allergies (write N/A if you have none).
*
Your answer
List any prescription medications (write N/A if you have none).
*
Your answer
Does the student have permission to carry their own medicine?
*
Yes
No
Not Applicable
List any medical equipment required for flight/ground transportation, if any (write N/A if you have none).
*
Your answer
Medical Insurance Provider Name
*
Your answer
Medical Insurance Policy Number
*
Your answer
Primary Physician Full Name
*
Your answer
Primary Physician Phone Number
*
Your answer
Primary Physician Address
*
Your answer
Father's Full Name
*
Your answer
Father's Email
*
Your answer
Father's Cell Number
*
Your answer
Mother's Full Name
*
Your answer
Mother's Email
*
Your answer
Mother's Cell Number
*
Your answer
Name of Emergency Contact (other than parents)
*
Your answer
Relationship of Emergency Contact
*
Your answer
Emergency Contact Email
*
Your answer
Emergency Contact Cell Number
*
Your answer
Student T-shirt Size (men sizes)
*
X-Small
Small
Medium
Large
X-Large
Will student be returning with the orchestra group on 7/2/23 on one of our pre-reserved flights?
*
Yes
No
List up to 5 students you wish to request in your chaperone group (for info collection only; no guarantees).
*
Your answer
Has the student been certified in first aid training within the past two years?
*
Yes
No
Has the student been certified as a life guard within the past three years?
*
Yes
No
List any other important information that our tour staff and adult chaperones should know about you.
Your answer
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