Participant Trip Profile and Contract:
YES, I’d like to join a Do Good Adventures tour !
Please complete this application and send it to us with your payment and a copy of your passport to Steppin’ Out Inc. , in U.S. dollars. Our street address is: 575 Carlisle Ave, Deerfield, IL 60015
|First Name: Middle Name: Last Name:|
|Additional Names in your party:|
|Date of Birth: Country of Birth:|
|Date of Birth:|
|Current Address: City|
|State: Zip: Country:|
|Mobile Phone: Do you receive Text Messages?|
|Emergency Contact: Relationship to Contact:|
|Contact’s Hm Phone: Contact’s Cell:|
|Health Insurance Carrier and Policy Number: Health Insurance Phone Number:|
|Physician’s Name and Number :|
|List other destinations that you have traveled to:
What do you hope to get out of this trip?
|Please let us know about any of the following:|
Symptoms of Allergy
Any Medication taking
Generic Name of Med
|List any dietary restrictions:|
|List any physical disabilities/impediments|
|Do you have a roommate request?Smoker ( ) Non- Smoker ( )|
PLEASE FAX BACK TO 877.264.7694
Check one of the two options:
1 I, _____________________________ am sending a check for the amount totaled above payable to Steppin’ Out at 575 Carlisle Ave, Deerfield, IL 60015. I will provide my credit card information below as a guarantee that the check will be sent, but I understand it will not be charged, unless Steppin’ Out does not receive my check within 10 business days from the date above. Steppin’ Out will notify me before charging.
1 I , authorize Steppin’Out to charge my credit card with an additional 4% added to the base price which totals _________________.
AGREEMENT: Please initial
______I understand that if payment is not received by Steppin’ Out within 8 business days, and/or should the trip offer an installment plan, and I am late with one of the installments, Steppin’ Out has the authority to charge my credit card with a 4% transaction fee.
______If I received an early bird discount, I agree to provide all information and payments accordingly, and should Steppin’ Out need to remind for payments, etc. then the early bird discount will no longer apply.
______I agree to the cancellation policy in this document and understand that if I cancel before payment has been made in full, that I am still obligated to pay the percentage/balance due.
______ I understand that this is a group trip and if I opt out of an activity, there will be no refunds for an activity not done. Should the group decide while there as a whole to do a different activity, the price of the new activity will be paid for individually.
_______ I understand that small group travel provides flexibility, but also understand that reservations have been made and that this is an active trip, to accomplish all the great things we want to do, I will adhere to the group time schedule.
_____ I understand that the cancellation policy is as follows: Prior to 120 days, only a $100 admin fee will be incurred, 120-90 Days prior to departure date, all but 25% of the full land fee will be returned; 90-60 days prior to departure 50% of full land fee will be retained, No refunds 61 days on prior to trip If ticket has been purchased, you will receive the ticket.
___ I understand that this is a physically demanding tour ,meaning that I’ll climb lots of stairs, do a fair amount of standing,carry my own bag up several flights of stairs and from the bus to my hotel room, walk an average of 6-10 miles per day, and won’t be allowed to smoke indoors during the tour unless I’m on fire.
Responsibility: All tickets and vouchers covering ground transportation, hotel accommodations, or other items in the package are issued by Steppin’ Out only as an agent for such companies furnishing such services. Neither they nor their subagents shall be held liable for loss or damage to property or injury to person caused by reason of any defect by any transportation company, lodging company, car company, resort area, agent or any service/item in the package outside their direct control. Steppin’ Out reserves the right to make changes and alterations in the itinerary that are found necessary for proper handling of tours. In such an event, substitute services or equal or greater value will be furnished, or refunded, but the alternate services will still fall under the liability statements above. Steppin’ Out shall not be liable for any loss, damage, injury, accident, delay or irregularity which may be occasioned by reason, defect, or through acts of omissions of any person or company described in the confirmation. In the event of a group or bulk ticket, Steppin’ Out is not responsible for any default of the airline. Should a dispute arise, venue shall be in the State of Illinois.
IF YOU ARE SENDING A CHECK, YOU MUST STILL PROVIDE A CREDIT CARD # for HOLD
I have read and agree with the agreement section of this document and authorize payment as indicated in the checked off box above. Mastercard or Visa Only
Credit card Number _________________________________ exp. Date ____________ Security Code: _____
Client’s Signature Agreeing to the above with date PRINTED NAME
PER OUR INSURANCE REQUIREMENTS, IT IS REQUIRED THAT YOU FILL OUT ONE WAIVER FORM FOR EACH EVENT. PLEASE MAKE COPIES FOR FUTURE EVENTS. THANK YOU. WE APPRECIATE YOUR HELP. PLEASE FILL OUT COMPLETELY.
PARTICIPANT AGREEMENT, RELEASE AND
ACKNOWLEDGEMENT OF RISK
In consideration of the services of Steppin’ Out, Ltd. DBA Do Good Adventures their agents, owners, officers, volunteers, participants, employees, contractors and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as “Steppin Out”), I hereby agree to release and discharge Steppin’ Out on behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows:
- I acknowledge that EVENT: _______________on the following dates: _____________entails known and unanticipated risks which could result in physical or emotional injury, paralysis, death or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity.
Furthermore, Steppin’ Out guides have difficult jobs to perform. They seek safety, but are not infallible. They might be ignorant of a participant’s fitness or abilities. They might misjudge the weather, the elements, or the terrain. They may give inadequate warnings or instructions, and the equipment being used might malfunction.
- I expressly agree and promise to accept and assume all risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.
- I hereby release, forever discharge, and agree to indemnify and hold harmless Steppin’ Out from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of Steppin’ Out’s equipment or facilities, including any such Claims which allege negligent acts or omissions of Steppin’ Out.
- Should Steppin’ Out or anyone acting on their behalf, be required to incur attorney’s fees and cost to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.
I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I certify that I have no medical or physical conditions which could interfere with my safety in this activity, or else I am willing to assume – and bear the cost of – all risks that may be created, directly or indirectly, by any such condition.
By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court to have waived my right to maintain a lawsuit against Steppin’ Out on the basis of any claim from which I have released them herein. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portion shall remain in full force and effect.
I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.
Signature of Participant:_________________________________ Print Name:_______________________________
Participants Address:___________________________________________________ Current Date: ____________
City, State & Zip ____________________________________________________________________________
Health Insurance Provider/Carrier:____________________________ Policy Number:________________________
Health Insurance Provider/Carrier Telephone Number: _________________________________________________
Social Security # ________________________________________________ Date of birth____________________
In case of emergency, please contact (specify relationship);_____________________________________________
Emergency contact’s telephone number:____________________________________________________________
On a scale of 1-10, with 10, being very active, how would you rate your physical activity? ______________