Journey Registration Form

(Required fields are marked with an asterisk. We require a $500 deposit, including $100 non-refundable registration fee, payable after you submit the form.)

Name (as it appears on passport) *

It is very important that you enter your name exactly as it appears on your passport.

Address *

Country

City

State

Zip code

Social Security Number *

Date of Birth:*

Email *

Preferred Phone Number *

Other phone number

Emergency Contact Name *

Emergency Contact Phone *

Passport Number *

Passport expiration date *

If your passport is set to expire earlier than June 3, 2017, please apply for a renewal now. Your passport must be valid for at least six months beyond the date of your arrival in Vietnam.

Are you (check all that apply)

Active duty

Veteran

Military family member

Counseling professional

Clergy

Concerned citizen

When and where did you serve (if applicable)?

If your family member or loved one is active duty or veteran, please tell how you are related (spouse, child, parent, etc.).

If you are a Vietnam veteran or relative, tell us which areas of operation you wish to visit.

Please describe any experience you have working with veterans.

Professional License Type

Professional License Number

Have you read (check all that apply):

War and the Soul by Dr. Ed Tick

Warrior's Return by Dr. Ed Tick

Please explain any dietary restrictions.

Do you prefer a single (supplemental cost TBD) room? *

Double OK

Single preferred

Price is based on double occupancy. We will investigate single room options for those who need them.

Please describe special accommodations, if any, needed for disabilities.

We require a $500 deposit, including $100 non-refundable registration fee.

After you submit this form, you will be prompted to pay the $500 deposit, including the $100 non-refundable registration fee. Entire amount of $3,900 must be paid in full by October 1, 2016. Fee can be paid by check, money order, credit card, or Paypal.

Instructions

Phone

Number

Services