Register To Travel in China

First Name:             MI:               Last Name:               Gender:
Age:             Race:  


Street Address:         City:           State:  
Zip/Postal Code:             Email Address:  
Home Phone: - -         Work Phone:   - -         Cell Phone:   - -


Departure City         Return City:  
Emergency Contact Name:         Phone:         RelationShip To You:  


Double Occupancy With:   $   Or   Single Occupancy Supplement $
Seasonal Charge $:         Payment Date: // (dd/mm/yyyy)         Departure Date: // (dd/mm/yyyy)
Passport No.         Passport Expiration Date: // (dd/mm/yyyy)         Group Leader:  


Please tell us about any health problems that you currently suffer from and wish to receive
treatment for during your health tour in China.:
Where did you hear about the Teaching/Working in China Program?  


Terms of Service

I have read and accept all the terms described above.