Student Enrollment – BLiT Safaris

GENERAL INFORMATION

HAVE YOU TRAVELLED WITH BLiT BEFORE?

Yes
No

Name*

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email*

ADDITIONAL INFORMATION

Date of Birth

Sex*

Male
Female

DO YOU HAVE ANY ALLERGIES, DISABILITIES, OR SPECIAL HEALTH CONSIDERATIONS?*

if yes state the allergy.

PARENT / GUARDIAN #1

By completing this enrollment form you agree that your are the legal parent, guardian, or custodian of the participant. The individual designated as the Parent / Guardian #1 will be the primary contact for completing any necessary forms and waivers.

Role*

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

PASSPORT INFORMATION

Important: Passports must be valid for at least 6 months after your return. If you do not have a passport or will be renewing your passport before your trip, please skip this section for now.

Nationality

Country of Issue

Passport Number

Expiration Date:

Phone

This field is for validation purposes and should be left unchanged.

Student Enrollment Form

GENERAL INFORMATION

ADDITIONAL INFORMATION

PARENT / GUARDIAN #1

PASSPORT INFORMATION