Trip Registration Form

Terms and Conditions

I understand that this registration will be valid only after a non-refundable deposit of $350 for each passenger. This will cover the cost GCA incurs for the transportation to and from Haiti. The total amount due for this trip is $1400 (including airfare to Haiti) and must be received by our office no later than one month before the expected travel time. You accept these terms by submiting this form.

Name:	First: Last:
Address:
City:	Zip:
Phone Number:	( ) -
Email:

Name as it appears on Passport:
Passport number:
DOB:	Passport Expiration Date:

Emergency Contact Information
Name:	Phone:
Email:

Name:	Phone:
Email:

For more information please call our office at (954) 319-3242 or by email: info@gcanet.org
Also, you can contact team coordinator Frank Maiorana
(305) 753-5006 or frank@gcanet.org