Simply Medjugorje

Pilgrimage Registration

Medjugorje Pilgrimage Dates (Drop-down selection)

Departing Airport

Name: First/Middle/Last exactly as shown on Passport

Name Preference for Name Tag (Nickname?)

Phone

Birth Date

Multi-line address

Country/Region

Address

City

Zip / Postal code

PASSPORT #

Expiration

Issuing Country

PASSPORT COPY - Upload here. If not possible, scan or take photo and send by email to pjflore@aol.com, or text to (818) 307-4332.

PASSPORT EXPIRATION

Passports must be valid for 6 months beyond scheduled return date. If it expires before, please submit Passport for renewal as early as possible.

OPTIONS

Double Occupancy

Private Room

7-Night Extended Trip

Extended Private Room

Roommate request

SPECIAL NEEDS/REQUESTS - WE'LL TRY OUR BEST TO ACCOMMODATE ALL

Wheelchair

Lower Floor Room (Limited)

Diet Restrictions/Allergies

Other

$500 non-refundable deposit required to secure registration. Upon submission of this form we will contact you with payment options. Travel Insurance is highly recommended, with personal options available thru

"InsureMyTrip.com" and others.

Payment in full due 10 weeks prior to departure date.

I acknowledge review of "Simply Medjugorje" Terms and Conditions, available on website via tab above.

SIGNATURE If unable to actually "sign," typed full name is acceptable.

Signature field is empty.