JSHS National Symposium -- Adult Guest Registration

Important Note: To avoid delays in boarding your airline flight you should be sure the "first name with middle initial or middle name" and "last name" as appear on this form are the same as appear on the form of identification you will be using to board your airline flight.

JSHS Guest Registration

Date of pre-registration and request for airline tickets: 2010-07-30 15:53:06

Organization:
First name with middle initial or middle name:
Last name:
Social Security Number:
Email address:
Choose your regional symposium:
Participation:
I am a	Male Female

Citizenship:

Are you a U.S. citizen? Yes   No

If not, the following is required information:
Nationality:
Date of Birth Month:   Date of Birth Day:   Date of Birth Year:
Place of Birth, City:    Country:
Permanent Resident ID # (if applicable):

Mailing Address:

Street Address:
City: State:
Zip Code:

For DoD Dependents School students:
Enter your APO address:

Preferred Telephone Area Code:
Preferred Telephone Number:
When can we reach you?

Secondary Telephone Area Code:
Secondary Telephone Number:
When can we reach you?

Travel Reservations

Arrival date: (in the form of yyyy-mm-dd)
Departure date: (in the form of yyyy-mm-dd)

For travel reservations and discounted pricing, please contact
the official travel agency for the National JSHS Program:

Sandy Delude
Penny Pitou Travel Service
Tel. 603-224-5337; Fax: 603-224-7028
email: sandy@pennypitoutravel.com

Special Personal Requirements

Check one if applicable:
Vegetarian (dairy and chicken) Vegan (no dairy) Kosher
Gluten Free Other

Food allergies/other dietary restrictions (NOTE: Special dietary needs will be accommodated only if notified in advance of the National symposium):

If applicable, specify special assistance required due to a disability:

Tour Choices

Please see www.jshs.org for detailed tour descriptions.
Select your first and second preferences from the list below.
Tours are limited to participation by student delegates, teachers, and adult leaders only.

Thursday Tours, First Choice:
Thursday Tours, Second Choice:

Hotel reservations and meal fees

All hotel reservations must be made through the National JSHS Office.

Military personnel must pay the hotel directly for hotel costs.
All adult guests sponsored by the National JSHS Office are assigned two per room. If
a single room is requested, please submit payment for the balance of room costs.

Room preference (check one):
No hotel room requested
Single room (one bed, either one or two guests)
Double room (two beds)
Shared room with another adult leader

How many nights did you want the room for?
Roommate request:

Calculating your Amount Summary

A registration fee is requested to defray attendance costs not supported through military sponsorship. We encourage you to seek support for this registration fee and/or discuss this with the regional symposium director. For your convenience, you can submit payment with your registration by credit card. Once you've submitted your registration (below), you'll have the opportunity to pay via a secure server. Your total payment will include meals, hotels, and the registration.