QUEENWOOD Music Tour to Eastern Europe - September 2017 NOMINATION FORM (please print clearly)
TOUR MEMBER
** Name as it appears on Passport
Surname: ** Given Names: ** Postal Address: P/Code
Suburb Home Tel: Instrument/s: PASSPORT DETAILS
* Validity of 6 months from date of return to Australia required ** Please attach a photocopy of passport unless already supplied
Passport No.
Date of Birth:
Country if not Australia:
Re-Entry Visa No. to Australia (if req)
Country of Birth: Nationality: PARENT/GUARDIAN NEXT OF KIN (1):
(As shown on passport)
Expiry Date:
Title: please circle
Name:
Dr/Mr/Mrs/Ms/Miss
Relationship: Home Address: Suburb Tel: (home) Tel: (mobile) PARENT/ GUARDIAN NEXT OF KIN (2):
P/Code Tel (work): Email:
Title: please circle
Name: Relationship: Home Address: Suburb Tel: (home) Tel: (mobile)
P/Code Tel (work): Email:
Dr/Mr/Mrs/Ms/Miss
MEAL REQUEST
SPECIAL DIETARY REQUIREMENTS
I wish to nominate for the above named tour and agree to accept the Tour Conditions applicable to this tour. SIGNED………………………………………………
SIGNED:…………………………………………………
(Student)
(Parent/guardian)
Deposit payment of $650 must accompany this nomination and be sent to the Music Department by Friday, 9 September 2016. Payments should be made by credit card to the school via the attached form below. Nomination Forms should be returned to the Music Department by Friday, 9 September 2016 * This information is critical as failure to provide correct information may incur additional costs. WHEN NOMINATING FOR THE TOUR, PLEASE COMPLETE THE NOMINATION FORM AND RETURN THE COMPLETED FORM TO THE MUSIC DEPARTMENT. PLEASE RETAIN THE TOUR CONDITIONS. -------------------------------------------------------------Music Tour to Eastern Europe Deposit
Daughter’s Name: ……………………………………………………………………………… Charge my Credit Card type:
American Express /
Visa /
Mastercard
Cardholder Name: ……………………………………………………………………………… Card No:
Expiry No:
/
Signature: ………………………………………………………………………………
Aug-16