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 Olympic in US funds) $75 nonrefundable, unless ADK cancels trip.
Balance due  March 1, 2004  $510
TOTAL COST: $810

CANCELLATION POLICY of Trip Outfitter/Agent/Guide: OPI.
No refund after Mar 15 on deposit.  If cancellation occurs after May 15, no refund on balance due. 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:____________