Personal ID & Waiver form Printable Form Please provide information requested below. Submit the completed document to Lisa Ball digitally, by mail, email or you can call with your personal information. Thank you! "*" indicates required fields HiddenToday's Date MM slash DD slash YYYY Personal Contact InformationFull Name* First Middle Last Your full name as it appears on your passport or government issued IDAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Date of Birth* MM slash DD slash YYYY Phone*Mobile*Medical InformationPlease describe your overall general health, any allergies or mobility issues you have, any special diet requirements (i.e. vegetarian, gluten-free), any special needs you have and/or any other medical conditions that you feel is necessary to disclose:Medical InformationEmergency InformationYour primary care physician:* First Last Your primary care physician's phone*Your primary Emergency Contact (not going on trip)* First Last Emergency Contact Phone*Secondary Emergency Contact (not going on trip)* First Last Secondary Emergency Contact Phone*Travel DetailsDo you plan on traveling with a spouse or guest?* Yes No Are you interested in sharing a room or having a single room and paying the single supplement? Share a Room Pay for single supplement Name of your spouse or guest: First Last If you are traveling as a single, who will be your roommate? First Last Tour Release Form2019 Lisa Ball Travel Design Tour Release Form and Authorization of Medical Care Waiver Lisa Ball as tour director and Lisa Ball Travel Design, LLC (LBTD) will make every effort to protect the welfare and safety of the participants in all tours led by LBTD on behalf of Village Presbyterian Church. Recognizing that participation in any LBTD Tour is voluntary and there are certain inherent risks which the participant must assume when traveling, the participant understands that LBTD, Lisa Ball as tour director and any LBTD staff members involved and Village Presbyterian Church staff involved do not assume any responsibility for damage to or loss of personal property, personal illness, injury or death while a participant is on a tour. Participants are advised to check their current medical insurance coverage to make sure they are adequately covered while traveling. Information on how to obtain additional travel medical coverage insurance and trip interruption and cancellation insurance can be provided by the tour director. Please sign the following statement as an indication that the above conditions and limitations are understood and accepted. I, as a participant in a Lisa Ball Travel Design Tour, hereby release Lisa Ball as tour director and Lisa Ball Travel Design, LLC, and any LBTD staff members involved and any Village Presbyterian Church staff involved for any and all claims and causes of action for damage to or loss of personal property, medical or hospital care, personal illness or injury, or death arising out of any travel or activity conducted by or under the control of Lisa Ball Travel Design, LLC. Participant’s Signature First Last Today's Date* MM slash DD slash YYYY Medical Care Waiver On occasion emergencies may arise which require medical care, hospitalization, or surgery for a participant. So that such treatment can be administered without delay, we ask that each participant sign the following statement authorizing Lisa Ball as tour director and/or LBTD staff members involved and Village Presbyterian Church staff members abroad to secure, at the expense of the participant, any medical treatment deemed necessary. In the event of injury or illness to the undersigned participant during a Lisa Ball Travel Design Tour, I hereby authorize Lisa Ball as tour director and/or LBTD staff involved or Village Presbyterian Church staff involved at my expense, to secure any necessary treatment including the administration of an anesthetic and surgery, and such medication as may be prescribed by a medical professional. It is further agreed that, if my condition so requires, I may be returned home at my own expense.Participant’s Signature First Last Today's Date* MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
