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Name___________________ Street__________________________ City/State/Zip_______________________ Birth Date ___________ Phone No. ____________________ Cell No. __________________ Email ________________________ Amount Enclosed __________ Traveling Companion____________________ Birth Date_________ Street_____________________ City/State/Zip_________________ Phone No. _____________________Cell No. __________________ Email Address__________________ Smoking___ Non-Smoking____ (Will request - No guarantee) Accommodations: 1 bed______ 2 beds______ First name(s) you want on nametag(s)_______________________ Emergency Contact Name & Phone__________________________ ________________________________________________________ Doctor's Name, address & phone number______________________ ________________________________________________________ List of medications _______________________________________ Special Dietary Needs _____________________________________ I will load the motor coach in: Elkhart___ South Bend ___ Niles ___ LaPorte ___
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