P. O. Box 9

604 Elm Street

Bunker Hill, KS 67626

www.shptv.org

 

785.483.6990

785.483.4605 FAX

Come Along Travel Club Reservation Form

 

Name and Dates of Trip:

Wisconsin Quilters Trip, September 7-11, 2011

Date:

 

NAME:

ADDRESS:

CITY:

STATE:

 

Phone:

Cell:

Birth date:

 

Email Address:

 

 

 

 Preferred names for name tags:

 

 

 

 

 

 

 

 

 

 

 

Room Preference

Non Smoking                           Smoking                           

Room Accommodations:

 

 

Special Needs or Requirements:

Single             Double                   Triple                 Quad

Rooming with:

 

 

 

Desire motorcoach pickup 

  Hays            

  Salina

 

 

Reservation Deposit:Due Date

Reservation Deposit Amount

 

 July 1, 2011

$75.00

 

             

 

   

 

 

 

 

 

I/We desire Travel Guard Insurance protection for this departure   Yes         No

 

 

 Average cost of insurance is $55-$75 per person. This is an additional charge to be paid with trip deposit. Please call for rates and coverage. By checking no I have rejected the offer by Smoky Hills Public Television and World Travel Center  for Travel Guard Insurance.

 

 

 

 

SIGNED:_______________________________________________ Date: ____________________

                               

NOTE: Travel Guard Insurance is offered to each individual reserving on this departure.  It is an added expense, not included in the trip cost or required deposit.  A general description of coverage and protection provided is available from World Travel Center, 785-827-0496. Traveler hereby agrees to assume all risks of loss, or liability, arising out of the trip that traveler is undertaking under this agreement. Traveler, on behalf of its heirs, and assigns, hereby releases Smoky Hills Public Television and their officers, directors, agents, employees, successors, and assigns (the “released parties”), from any and all liability for damage to property or injury or death of any person. Traveler acknowledges that travel carries certain risks and that the traveler is voluntarily under-taking this optional recreational activity and that the released parties shall have no liability to traveler for property damage or personal injury unless due to the willful misconduct of the released parties.

 

 

Total Cost:
 

Deposit Received:
 

Balance Due: