Trip Leader:     Mary Coffin 
Address:    328 Deepsprings Dr., Chittenango, N.Y. 13037 
Phone/fax,e-mail:   315-687-3589    <mccoffin721@worldnet.att.net> 
Deposit Required to Register: $300 (checks made payable to ADK Boundary Waters-04 in US funds) 
Balance due June 10, 2004  $535
TOTAL COST: $835

Outfitter Cancellation Policy ( beyond ADK $75 non refundable): Cancellation must be made 45 days in advance of reserved date to receive refund of deposits on canoe rental and guide services. A $25 reservation fee is non-refundable.If a bona-fide emergency requires early termination of your completely outfitted trip, you will receive a refund of equipment costs only (no food refunds) for unused days, minus one day.  No refunds are made for early termination of partially outfitted trips.

If the trip is cancelled by ADK or if the Leader rejects the applicant, the entire deposit will be refunded.

Name (as it appears on passport): ________________________________

Address: ___________________________________________________ zip__________

Phone/fax/e-mail: _______________________________________________ 

Passport #: _____________________Expiration Date:_________  Sex: F___  M___ 

ADK Membership #____________ Chapter _____________________ 
All trip members must be current ADK members. If you are not a member, contact ADK headquarters at 800-395-8080, or adk.org for an application form.

IN CASE OF EMERGENCY NOTIFY:
Name : _____________________________  Relationship: __________________ 

Address: ___________________________________________________zip__________                       

Phone Number(s): _____________________________________________________

Print your name as you wish it on your ADK Name Badge: _________________________

ATTACH and SEND to Trip Leader at the address above:
__Deposit (check made out to ADK in U.S. funds or credit card authorization)
__Signed copy of Release of Liability Form. 
__Health Questionnaire

SIGNATURE: _______________________________   Date:____________