NAME:________________________________________________________ MALE___ FEMALE____

YOUR HOME COUNTRY____________________ YOUR E-MAIL ______________________________

HOST ROTARY CLUB______________________ HOST DISTRICT________"T" SHIRT SIZE _____

(s-small m-medium L-large XL)

HOST CLUB CHAIRPERSON_____________________________________________

Name

_____________________________________________

_____________________________________________

City State Zip Code

HOST CLUB CHAIRPERSONS HOME PHONE ____ _____ _________ WORK ___ ____ __________

Include area code Include area code

I ______________________________, will abide by the designated rules and regulations of the DISCOVER AMERICA BUS TRIP. I also agree to the attached limits of responsibility.

STUDENT SIGNATURE__________________________________________________________________

I have reviewed the attached rules with the student and am confident he/she will abide by the rules and regulations. I also agree to retain an emergency fund of no less than $200 from the student to be release to the bus trip in case of an emergency regarding this student.

SIGNATURE______________________________________________________________________

HOST CLUB CHAIRPERSON

We (I) agree that our/my son/daughter will abide by the rules of the DISCOVER AMERICA BUS TRIP and furthermore permit the chaperones to allow medical treatment for my child while on the trip. We (I) have attached a list of any and all medical history he/she has that might affect them during the trip.

NATURAL PARENTS SIGNATURE________________________________________________________

I will get on the bus in: Albany__ / Binghamton___/ Oneonta___/ Syracuse___/ Rochester___/ Horseheads___/ Phila. area___/ Clark Summit___.

On the return trip I would like to get off the bus in: Albany___/ Binghamton___/ Oneonta___/ Syracuse___/ Rochester___/ Niagara Falls___

The READABLE, COMPLETE application must be received with full payment, Insurance, and Exchange student card no later than April 25, 2007. If the trip is full before April 25 your application will be placed on an alternate list. If your application is not complete or we cannot read it you will not be put on the trip until it is corrected. Anyone withdrawing from the trip prior to April 1, 2007 will receive a refund of approx. $1,600. Any cancellations after April 1, 2007 but before June 1, 2007 will receive a refund of approx.$850 and any after June 1, 2007 will receive no refund.

Any questions you can reach Michael Wilcox at (607) 967 8501 days or e-mail mrwilcox@MKL.com