Trip Dates - Project FIAT

Group, if any, with whom you are traveling (school, parish, or organizer name)

Date of FIAT TRIPS 2019*

* Groups of 10 or more may apply for dates not listed by contacting Lynette Kyle at info@projectfiat.org

T-Shirt size

Your Name*

Address*

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

(Other countries please apply using our printable form.)

Daytime Telephone*

Evening Telephone

Email Address*

Date of Birth*

Gender

Male
Female

Passport

Passport Status*

I already have my passport.
I have applied for my passport.

Your name how it will appear on your Passport*

NAME MUST MATCH PASSPORT OR THERE WILL BE A CHANGE FEE FOR AIRLINE TICKET

Country of passport*

Country

Passport Date of Issue*

Passport Date of Expiration*

Nationality (according to passport)*

Expected Date of Receipt of Passport*

Health Insurance

Health Insurance Confirmation*

I have health insurance that will cover me abroad.
I do not have health insurance that will cover me abroad, and will be responsible for any health related expenses that occur.

Health Insurance Carrier

Policy Number

Group Number, if applicable

Name of Insured

Relationship of Insured to Applicant

Insurance Company Telephone

Please list any allergies*

e.g. Food, Latex, Medicine, Environmental

Emergency Contact Information

Emergency Contact Name

Relationship to Applicant

Daytime Telephone

Evening Telephone

Contact Information for Parents

Contact information for parent(s) is required for students. This information is optional for others.

Father's Name

Father's Address

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

Father's Daytime Telephone

Father's Evening Telephone

Mother's Name

Mother's Address

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

Mother's Daytime Telephone

Mother's Evening Telephone

Did we forget anything? If there's more you would like to tell us about yourself, include it here

Agree to Policies*

I have read and agree to the policies of Project FIAT International as detailed in the Project FIAT Manual.