Adult / Chaperone Application for China Trip

All required fields are listed in "Bold"
Name
Primary Address:
Email address:
Phone number:
Mobile phone number:
Emergency contact info:
Birth date (mm/dd/yyyy):
Gender:	Male Female
Occupation:
Are you trained in CPR:	Yes No
Has one or more of your children applied to go on the trip? If yes, give name/s
Orchestra:	BYS LYSO CYSO Other
What medication do you take regularly (if none, then enter "none")?
What medication will you be bringing with you on the trip (if none, then enter "none")?
Give details of any allergies (if none, then enter "none"):
Please specify any dietary restrictions or preferences you have (if none, then enter "none"):
Describe any physical or emotional conditions you have that may require special treatment or attention at any time during the trip (if none, then enter "none"):
List name and contact information for any medical insurance you may have that would provide coverage while you are outside the U.S. (if none, then enter "none")	;
Would you like to obtain trip cancellation or trip interruption insurance, depending on cost? If so, which?	Trip Cancellation Trip Interruption Insurance
Do you have a passport?	Yes No
Passport expiration date (mm/dd/yyyy):
I would like to bring with me:	Laptop Mobile phone Camera
I have the following vaccinations that are valid for a period that expires after June 17, 2010:
I would like to book my flight to Hong Kong from Denver and from Shanghai to Denver myself rather than have BYS book these flights for me:	Yes No
Would you prefer a single room, depending on the cost?	Yes No
If you have to share a room, give name of person you would like to share with:
Is there anyone who may be going on the trip with whom you would not want to be assigned the same room? If so, who?
Have you been to China before?	Yes No
Can you speak the following Chinese languages? Indicate which:	Mandarin Wu Yue Min
Can you read the following Chinese languages? Indicate which:	Mandarin Wu Yue Min
Do you play any musical instruments? If yes, which?
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