<p> APPLICATION FORM</p><p>American Latvian Association „Hello, Latvia!” / „Sveika, dzimtene!” 2017 Tour of Latvia</p><p>The trip cost will be approximately $2500, based on double occupancy, and consists of the “land portion only.” Participants will make their own arrangments to meet the group in Riga on July 15, 2017. The maximum number of participants is 20. Please send in your deposit as soon as possible, since participants are signed up in the order that their applications and deposits are received. </p><p>I am signing up for the ALA 2017 “Hello, Latvia ” trip and enclose a deposit of $500___. (The deposit, less $100, is refundable if I cancel my participation by May 15, 2017; The remainder of the trip fee is due by May 15, 2017. If you cancel after May 15, 2017, you forfeit $300 of the deposit.</p><p>Name: ______</p><p>Address:______</p><p>______</p><p>Home Tel.:______Cell Phone:______</p><p>E-mail:______</p><p>Date of Birth:_(day, month, year, i.e., 5 March 1950 )______</p><p>U.S. Passport #______</p><p>Latvian passport #, if applicable______</p><p>I enclose a deposit of $500______</p><p>I would like to pay a supplementary fee of $500 for single-room occupancy______.</p><p>Hello, Latvia Application Form Page 1/4 Heritage Latvia Application Form Page 2/4</p><p>To participate in the „Hello, Latvia!”/ „Sveika, dzimtene!” trip, you must be a member of the American Latvian Association:</p><p> I am currently a member of ALA: ______Membership category: ( circle one): Annual; Life member; Gold life member; Amber life member </p><p> I would like to become a member of ALA and include a separate check made out to ALA for the appropriate membership fee Annual Membership - $30 ______Life Membership - $300 ______Gold Life - $800 ______Amber Life $2,000 ______.</p><p>What area of Latvia are you or your relatives from? ______</p><p>______</p><p>Besides your family’s area of origin, is there any other place you would particularly like to visit in Latvia?</p><p>______</p><p>______</p><p>Describe any dietary restrictions/allergies you may have______</p><p>Do you have any challenges with walking for up to ½ mile or climbing in/out of the tour bus? Describe:______</p><p>Describe any medical issues of which the group organizer and group leader should be aware______</p><p>______</p><p>Please provide us with a Doctor’s statement clearing you for travel by May 15, 2017.______. Hello, Latvia Application Form PAGE 3/4 </p><p>Terms and Conditions of Participation in the 2017 American Latvian Association (ALA) – sponsored “Hello, Latvia!”/”Sveika, dzimtene!” Program</p><p>1. I, the participant, agree to pay full fees and costs associated with the “Hello, Latvia!”/”Sveika, dzimtene!” program to ALA, as outlined in the program information, no later than May 15, 2017. The $500 deposit LESS $100 is refundable until May 15, 2016. After May 15, 2017, the $500 deposit LESS $300 is refundable.</p><p>The trip fee in its entirety is due by May 15, 2016. </p><p>2. I, the participant, will sign a medical release form authorizing emergency medical treatment, if and when deemed necessary by the group leader and/or consulting physician and will not hold ALA responsible for any actions relating to the emergency treatment. I agree that I am responsible for all medical expenses incurred during the trip including the cost of medical evacuation from Latvia. It is my responsibility to obtain adequate medical insurance to cover these and other unnamed contingencies or to cover these costs myself . I will provide medical insurance information to the organizers.</p><p>3. I, the undersigned, represent to ALA that the risks attendant to this trip have been explained to me by representatives of ALA, acknowledge that the trip has been arranged for the benefit of the participants as a service to its members by ALA, and hereby waive any and all claims against ALA, its agents or employees, whether arising within or without the United States, for any loss, damage, or injury whatever to persons or property, to include personal injury to the participant, arising out of or connected in any way with my participation in the “Hello, Latvia!”/”Sveika, dzimtene!” program. </p><p>4. I understand that I am responsible for any damage I may cause while on tour to hotel property or other facilities and agree to pay for any such damages without delay.</p><p>______Participant’s Signature Date</p><p>______Participant: Print full name Date </p><p>Hello, Latvia Application Form PAGE 4/4</p><p>ALA TRIP – “HELLO, LATVIA!”/“SVEIKA, DZIMTENE!” - SUMMER 2017 EMERGENCY INFORMATION FORM</p><p>Name:______Address:______Home Telephone:______E-mail:______</p><p>In case of emergency, please contact: Contact name: ______Address:______Home Telephone:______; Cell Phone:______OR Contact name:______Address:______Home Telephone:______; Cell Phone:______</p><p>Participant’s Health Insurance Company:______Group number/I.D. number______Contact telephone:______</p><p>Medical conditions of participant:______</p><p>______I attach a doctor’s statement outlining my current health issues, if any, as well as my vaccination records. OR ______I will provide this information by May 15, 2017. ______Allergies or dietary requirements:______I have purchased international travel insurance for this trip: ______The contact number is:______</p><p>NOTE: This information will only be used in the event of an emergency during this trip and will be returned to the participant at the conclusion of the trip if so requested.</p><p>______Signature Date</p><p>EMERGENCY MEDICAL RELEASE FORM</p><p>I hereby give a group leader (in consultation with the group’s designated local physician) permission to approve emergency medical treatment for me in the event that I am incapacitated and unable to request medical treatment myself:</p><p>Traveler’s signature______date______</p>