Trip Registration

"*" indicates required fields

Selected Trip*

Name*

Salutation Legal First Name(s) as per passport Legal Middle Name(s) as per passport Last Name(s) as per passport

First Name commonly used

Gender*

Female

Male

Other

Date of Birth*

mm/dd/yyyy

Passport Number*

Passport Country*

Passport Issue*

mm/dd/yyyy

Passport Expiration*

mm/dd/yyyy

Mobile or Primary phone*

Secondary Phone*

Primary Email*

Secondary Email*

Home Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Is the Credit Card Billing address different from above?*

Yes

Billing Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Dietary requirements and allergies

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact Phone Number*

Airline frequent flyer name and number

hotel membership name and number

Total number of adults in the room/cabin*

Please enter a number from 1 to 4.

Cabin type or category requested

Number of beds required*

one bed (queen/king)

two beds (twin/double)

Are you bringing Children?*

Yes

Children's Information*

full name

Birthdate (month/dd/yyyy)

Passport number

Passport date of issue

Passport date of expiry

Add a row for each child. Maximum 4 children.

Cruise line preferred dining (if applicable)

Early Dining

Late Dining

Anytime Dining

Prefer to dine with (friends/family) also travelling in the group:

Tourcan Vacations can assist with flights, transfers, and pre/post KPES travel arrangements. Tourcan Vacations is unable to assist with Aeroplan reservations. Would you like Tourcan Vacations to quote/book any of these additional travel components?*

Yes

Special requests (ie wheelchair assistance, airline meals or preferred seating)

Kennedy Professional Educational Seminars and Tourcan Vacations strongly recommends purchasing travel insurance to protect you against many unforeseeable circumstances. We recommend our travel specialist contact you to provide details.*

Yes, Please contact me

No, Do not contact me

“I’ve read and acknowledge the importance of speaking to a travel insurance specialist so I’m fully aware of all my insurance options and coverages. Although travel insurance can be purchased elsewhere, it’s important to fully understand the terms of each insurance policy as they differ vastly.*

I have purchased Travel Insurance elsewhere

I am declining Travel Insurance and will complete the below waiver to be sent to Tourcan Vacations

Download & complete this Waiver, then Email to Tourcan.

Dental/Medical Practice Name*

Seminar Registration Type*

KPES Dentist – Attending Seminar

KPES Auxiliary – Attending Seminar

KPES Speaker/Host

KPES Dentist Not attending seminar

Guest – Not Attending CE Seminar

Type of Practice/Specialty*

Other

Have you travelled with Kennedy Professional Educational Seminars in the past?*

Yes (1-2 times)

Yes (3-5 times)

Yes (6+ times)

No, This is my first KPES seminar

How did you hear about this trip and seminar?*

Referring Dental Colleague's Name*

Would you like to be added to the Kennedy Seminars email list to be notified of future dental seminars and trips?*

Yes, please add me to your email and mailing list

No, I do not want to receive future email or mail marketing

Terms and Conditions

Please review payment amounts, cancellation dates and penalties, full terms and conditions here:

View Kennedy Seminars

View Tourcan Vacations

(Terms and Condition links open in a new window)

Terms and conditions agreement*

I have reviewed and agree with the terms and conditions on the Kennedy Seminars and Tourcan Vacations websites.

Image Authorization

You acknowledge that both photographs and videos may be taken during this trip of its activities and of attendees, including yourself. For valuable consideration, you hereby give Kennedy Professional Educational Seminars Inc. and Tourcan Vacations permission to use photographs and videos of you. You authorize the use and reproduction of such photographs and videos containing your likeness and image for the Kennedy Professional Educational Seminars Inc and Tourcan Vacations websites, Facebook pages, Instagram accounts, marketing materials, instructional materials and other media without notification or further permission. You hereby release Kennedy Professional Educational Seminars Inc. and Tourcan Vacations from all claims and liability relating to said photographs and videos.

See the Terms and Conditions for more details

Image Authorization*

I agree to the image authorization terms set out above and in the Terms and Conditions

I do not agree to the image authorization terms set out above and in the Terms and Conditions

Are you bringing a Guest?*

Yes

Additional Guest

Name*

Salutation Legal First Name(s) as per passport Legal Middle Name(s) as per passport Last Name(s) as per passport

Guest Relationship*

Registration Type*

Guest – Not Attending CE Seminar

KPES Dentist Not attending seminar

KPES Dentist – Attending Seminar

KPES Auxiliary – Attending Seminar

KPES Speaker/Host

Gender*

Date of Birth*

mm/dd/yyyy

Passport Number*

Passport Country*

Passport Issue Date*

mm/dd/yyyy

Passport Expiration*

mm/dd/yyyy

Mobile or Primary Phone Number (if different than first guest)*

Primary Email Address (if different than first guest)*

Dietary requirements and allergies

Airline frequent flyer name and number

Hotel membership name and number

Name

This field is for validation purposes and should be left unchanged.

Destinations

Trip Registration

Additional Guest

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