2017 Pilgrimage to Ghana Application

1. 2017 Ghana Pilgrimage October 12-26, 2017

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Please complete all fields in this online application before the due date of March 1st, 2017.

If you have technical problems with the survey, please contact Beth at 414-758-2280. If you have questions about the program, please contact Antoinette Mensah at 414-758-2282

PAGE 1: PERSONAL INFORMATION:

Question Title

* 1. Please provide your contact information:

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. What is your date of birth? (please use format MM/DD/YYYY)

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* 3. Do you have a valid passport? (Passport must not expire for at least 6 months after the return date of your trip.)

Yes

Please Note: You do not need to have a passport to apply for the program. However, you will need to have a passport before July 1, 2017 as it is needed to book your flight.

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* 4. If you already have a valid passport, please enter the following information:

Full name exactly as it appears on your passport:

Passport Number:

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* 5. Emergency Contact Person(s):
(at least one person's name and phone or e-mail address is required)

Contact Person #1 Name:

Contact Person #1 Telephone Number:

Contact Person #1 E-mail Address:

(optional) Contact Person #2 Name:

(optional) Contact Person #2 Telephone Number:

(optional) Contact Person #2 E-mail Address:

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* 6. Do you have any health or dietary restrictions?

Yes (please specify)

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* 7. Rooming Preference:

Note: single occupancy is $600 additional

Double Occupancy

Single Occupancy

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* 1. Please provide your contact information:

Question Title

* 2. What is your date of birth? (please use format MM/DD/YYYY)

Question Title

* 3. Do you have a valid passport? (Passport must not expire for at least 6 months after the return date of your trip.)

Question Title

* 4. If you already have a valid passport, please enter the following information:

Question Title

* 5. Emergency Contact Person(s): (at least one person's name and phone or e-mail address is required)

Question Title

* 6. Do you have any health or dietary restrictions?

Question Title

* 7. Rooming Preference:Note: single occupancy is $600 additional

* 5. Emergency Contact Person(s):
(at least one person's name and phone or e-mail address is required)

* 7. Rooming Preference:

Note: single occupancy is $600 additional