Trip Signup Form
Applicant info:
Name of Traveler
Address City State Zip
Phone - - Email address
Agency/Individual Completing Form:
Primary Contact Agency
About the Trip:
Departing From: Select Departure City Liverpool, NY Palm Beach, FL
My first choice of Trip: Select one from the list. 1,000 Acres Dude Ranch / Oct 17-19, 2007 Buffalo Sports Fest / Oct 20-22, 2007 Disney World / Nov 13-15, 2007 Christmas with Rockettes / Nov 13-15, 2007 Caribbean Cruise / Dec 5-10 Florida Experience / Dec 15-19, 2007 Viva Las Vegas / Jan 11-15, 2008 San Antonio, TX / Feb 2-6, 2008 Baseball Spring Training / Mar 2-6, 2008 NASCAR NEXTEL Cup / Mar 17-20, 2007 Nashville, Tenn. / Apr 6-10, 2008 Washington, DC / Apr 18-20, 2008 1,000 Acres Dude Ranch / Apr 26-28, 2008
My second choice if other is not available: Select one from the list. 1,000 Acres Dude Ranch / Oct 17-19, 2007 Buffalo Sports Fest / Oct 20-22, 2007 Disney World / Nov 13-15, 2007 Christmas with Rockettes / Nov 13-15, 2007 Caribbean Cruise / Dec 5-10 Florida Experience / Dec 15-19, 2007 Viva Las Vegas / Jan 11-15, 2008 San Antonio, TX / Feb 2-6, 2008 Baseball Spring Training / Mar 2-6, 2008 NASCAR NEXTEL Cup / Mar 17-20, 2007 Nashville, Tenn. / Apr 6-10, 2008 Washington, DC / Apr 18-20, 2008 1,000 Acres Dude Ranch / Apr 26-28, 2008
Wheelchair is necessary for trip
Walker is needed for the trip
Mail information to: Applicant Only Agency Only
Comments: