Waiting List Registration

Young Adult Pilgrimage to Italy 2015

This form is to create a waiting list, in the event that we will decide to accommodate more people for the trip. Please fill it out and submit it and we will keep you posted. Thank you!

Name: *
E-mail: *
Confirm E-mail: *
Date of Birth YYYY-MM-DD: *
Phone: *
Permanent Mailing Address: *
Emergency Contact Name: *
Relation to me: *
Home Phone: *
Cell Phone: *

Special Needs

I am in good health and am able to hike a mountain and walk on uneven city roads without needing help. *
I have the following allergies or preexisting medical conditions that you should know about (food or medicine allergies, asthma, etc):
Do you speak Italian? 1 - 4 : *