UNIROPA Student Educational Holidays Inc.

Chaperone Agreement Form

Please press "Submit" after completing this form. Thank you!

Please make sure to read all the notes on the PDF form!

Group & Group Leader Information

Your E-mail:
Group / School Name:
Date of Travel:
Group Leader:
Title:	Mr Mrs Ms
Date of Birth:
Gender:
Passport #:
Country of Issue:
Expiry Date:
Do You Require Travel Insurance Through Uniropa:	Yes No
Do You Require a Single Room (supplement applies):	Yes No
Dietary Concerns:	Yes No
If yes, explain:
Medical Condition:	Yes No
If yes, explain:
Emergency Contact Number Where We Can Reach You While on Tour:

School Mailing Address

City:
State / Province:
Zip / Postal Code:
School #:
School Fax:
School Principal:

Home Mailing Address

City:
State / Province:
Zip / Postal Code:
Home #:
Emergency #:
Personal Email:

Terms and Conditions (acceptance of responsibility)

I have read, understand, and agree to the terms and conditions on the PDF Chaperone Agreement Form.
Signature of Student or Adult Participant:
Signature of Parent or Legal Guardian:
Date:

Please make sure to read all the notes on the PDF form!