Please print this page, fill in information, and mail to:

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 Chaco in US funds) Due with registration to reserve a place. $75 non-refundable.
Balance due Feb. 1, 2004  $685
TOTAL COST: $985

CANCELLATION POLICY of Trip Outfitter/Agent/Guide:
60 days prior= Full refund less $100, 45-59 days prior= 70% refund less $100, 30-44 days prior= 50% refund less $100.
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:____________