Application and Registration For Scientific Exchange Trip To Argentina, May 14 - May 21, 2007

YCS INSTITUTE SCIENCTIFIC EXCHANGE TRIP TO ARGENTINA
May 14– May 21, 2007.
(Tour Operations through Community Development Partners For The Americas, LLC)
APPLICATION AND REGISTRATION FORMS

YCS Institute for Infant and Preschool Mental Health
Scientific and Cultural Visit to Argentina.

DATES:
Departure: From New York, Monday, May 14, 2007 at 10:10 PM
Return: Monday, May 21, 2007, (6:00 AM arrival on the next day)

COSTS: $2,918.00/person- Double Occupancy (single rooms may be available on an optional basis with a price differential). Price includes a $150.00 registration fee to the YCS Institute. Price includes international roundtrip airfare (from NY), all lodging at 5 star Buenos Aires hotels, daily breakfast and either a gourmet lunch or dinner, all transfers and transportation to group activities, all scientific activities, all city tours, and all cultural and touring activities.

To submit your application and registration materials please copy, paste and email the materials below (or print and mail) to our trip organizers: Dr. Hune Margulies at: Hune@MartinBuberInstitute.org, or CDPA@cdpa-americas.org or Phone: 914-833-7787. cell: 914-439-7731.

You may also contact: Dr. Gerard Costa or Kathleen Mulrooney at YCS, 973-395-5500, Ext. 301


INSTRUCTIONS

1. Please sign and return this complete application and registration forms via e-mail to CDPA@cdpa-americas.org.
2. Print this entire application, include a check with your deposit and return to CDPA: 203 Rockingstone Avenue. Larchmont, NY 10538. (914-833-7787).
3. Attach to this application three photocopies of the first page of your passport and a copy of your health insurance card, back and front.

Part I: Personal Information

Full Name, title:
email address:
Date of Birth: Gender :
Social Security Number:
Occupation:
Home Address:
City: State: Zip code:
Home Phone: Cell Phone:
Spouse’s email:
Emergency email:
Fax : Work Phone:
web site:
Country of Residence: Place of Birth:
Citizenship:
Passport Number: Passport Expiration:
Health Insurance Carrier:
Name of insured:
Policy Number:
Work address:
Emergency Contact Name:
Phone Number:


Please provide us with a brief explanation as to special circumstances or concerns: (special diets, health issues, disabilities, etc.). Please describe in detail. All information is strictly confidential and it will be used solely for the purpose of arranging for special services as needed.


➢ Do you know Spanish?

➢ Need Special Diets?

➢ Taking Medications?

➢ Allergies?

➢ Other Health Issues?

➢ Disabilities?


Part II: Financial information:

Method of payment: Check, Money Order, Cash, (Partial Credit Card payments allowed). Make checks payable to: Community Development Partners For the Americas, LLC. 203 Rockingstone Avenue. Larchmont, NY 10538. 914-439-7731.

Part III: Instructions:

Total Cost: The cost of the Tour Program is $2,918.00 The price of the Program includes a $150.00 registration fee to YCS Institute, international round trip air fare (from NY), lodging at 5 star Buenos Aires hotels, two gourmet meals daily, all domestic travel and ground transfers to group activites, all entrance fees, all cultural, social and touring activities, all scientific program related activities, all social and entertainment events and materials. Price does not include airport taxes.
Payments: A deposit in the amount of $350.00 must accompany this application. Deposits and payments must be made within schedule to insure space in the program and to avoid late penalty charges. Optional price excluding international round trip air fare is: $2,357.00.
Deadline: Last date for receipt of applications is February 18, 2007. Full payment after deposit must be received by March 7, 2007.

Cancellations: Depending on airline, hotels, buses and other supplier’s policies. After receipt of application a voucher for your deposit will be issued and e-mailed.

Please Make all checks payable to: COMMUNITY DEVELOPMENT PARTNERS FOR THE AMERICAS. 203 Rockingstone Avenue. Larchmont, NY 10538, USA. Tel: 914-833-7787 / 914-439-7731. Email: CDPA@cdpa-americas.org . www.culture-and-ecology.com


Waiver and Release
Release executed on the___day of __________ , 200 __ , by ________________ (the 'Traveler Releasor') , resident of__________________________________________to YCS and CDPA (the 'Releasee').

I, the Releasor, in consideration of my participation in the YCS scientific exchange trip to Argentina, scheduled for May 14, 2007 - May 21, 2007, and run and/or operated by the Releasee, waive, release, and discharge the Releasee and CDPA and the MBIDE, its owners, officers, directors, employees, members, agents, assigns, legal representatives and successors, and all business associates and partners involved in the presentation of the above noted activity and each of them their owners, officers and employees, and any other people officially connected with this event from all liability for or by reason of any damage, loss or injury to person and property, even injury resulting in the death of the Releasor, which has been or may be sustained in consequence of the Releasor's participation in the activity described above, and notwithstanding that such damage, loss or injury may have been caused solely or partly by the negligence of the Releasee. I am aware of the risks of participation. I understand that participation in this program is strictly voluntary and I freely choose to participate. I understand that the Releasee does not provide medical coverage for me. I verify that I will be responsible for any medical costs I incur as a result of my participation


Date:
Name of Traveler:
Signature of Traveler
Name of Traveler
Signature of Traveler