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Conley & silvers

ITALIAN IMMERSION: MANTUA AND THE HIDDEN GEMS OF NORTHERN ITALY
PARTNERED WITH YALE EDUCATIONAL TRAVEl

Traveler Information forms

Passport Information:
Please complete one form for each traveler. List information EXACTLY as it appears on your passport.
Name (exactly as it appears on your passport) *
Name (exactly as it appears on your passport)
Please put first and middle names in the first name box.
Date of Birth *
Date of Birth
Passport Date of Issue *
Passport Date of Issue
Passport Date of Expiration *
Passport Date of Expiration
Contact Information
Phone *
Phone
Address *
Address
Traveler Preferences
Sleeping Arrangement *
Choose one
Food & Beverage Information:
To maximize your eating enjoyment please answer the following:
If vegetarian or vegan, please specify what you will/will not eat:
Beverages
Water
Check which water you prefer, or both.
Other Beverages
Check all that you like
Health Statement
Health Statement & Emergency Contacts: This trip involves substantial walking (often over uneven surfaces), hiking without hand rails, and traveling in summer temperatures. You will be in charge of handling your luggage a few times during this trip, including on and off of a train if going to Venice. You are fully responsible for your own healthcare and any related medical costs, hence our recommendation for travel and medical evacuation insurance. We also advise that you travel with a copy of your medical record and/or list of current medications, along with your doctor’s contact information. Please note any medical conditions, injuries, allergies (to medicines or other), current medications, or other health-related concerns that we should be aware of while you are on this trip, or feel free to send us electronic or paper copies of any documentation that you think might be helpful for us to have on file.
Acknowledgement of physical activity *
Doctor's Name *
Doctor's Name
In case of an Emergency, please give us the contact for your doctor:
Doctor's Phone Number *
Doctor's Phone Number
Emergency Contact
Please provide contact information for someone besides your travel partner in case of an emergency.
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone Number *
Emergency Contact Phone Number
Additional Information
Italian Language Proficiency *
To help us determine your Italian language level, please indicate which best describes you. Note you can always shift levels at any point on our trip.