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Registration Form

Party members First Name Last Name Date of Birth Male/ Female Room Type Twin Double Twin Single Bike rental ? (Please provide your height) Shirt size Contact information Name:____________________________________________________________ Address:__________________________________________________________ _________________________________________________________________ _________________________________Post Code:_______________________ Passport:_________________________________________________________ Telephone:________________________________________________________ Home:_________________Work: _________________Mobile: ______________ E-Mail (Please print clearly)___________________________________________ How did you find out about us:______________________________________ Selected tour:___________________________________________ Selected date:___________________________________________ Special Requests / Restrictions (Medical Condition, Dietary Restrictions, etc.): ___________________________________________ ___________________________________________Emergency Contact: Name(s):___________________________________________ Relationship:___________________________________________ Phone numbers:___________________________________________ Payment Information: Deposit: 30% of tour cost is required to reserve your space(s). Thank you. Card: Visa, MasterCard, American Express Name on card:______________________________ Card number:_____________-_________________-______________-________________ Expiry date: Month:________ Year:________ Security Nº (Last 3 digits on signature panel) :______________ I, ___________________, the card holder, authorize Israel Cycling, to take the deposit and the balance on the due date or shortly after. Signature_________________ Clients Declaration: I have read and accept on behalf of all members of the party named above, the Form of Agreement, terms and booking conditions of Israel Cycling. Name:______________________Signature:______________________________ Date:_______________________ With your booking form, you MUST enclose, for each member of the party named above: 1. Signed insurance statement form 2. Photocopy of the insurance details

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