Trip Registration Selected Trip* Name* Mr.Mrs.MissMs.Dr.Prof.Rev. 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 Prefer not to answer Date of Birth* Month Day Year Passport Number* Passport Country* Passport Issue* Month Day Year Passport Expiration* Month Day Year Mobile or Primary phone*Secondary Phone*Primary Email* Secondary Email* Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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.Total number of children in the room/cabin (12 and under)Please enter a number from 0 to 4.Enter ages of all children Cabin type or category requested Number of beds required* one bed (queen/king) two beds (twin/double) Cruise line preferred dining (if applicable) Early Dining Late Dining Flexible/Select 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 No 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* General Practitioner Oral Surgery Periodontist Prosthodontist Endodontist Orthodontist Restorative Medical professional Other Not Applicable 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?* Kennedy Seminars website Oral Health advertisement American Dental Association advertisement Dr. Jack Lipkin or Dr. Marshall Hoffer Dental Colleague Tourcan Vacations Travel Advisor 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 ConditionsPlease review payment amounts, cancellation dates and penalties, full terms and conditions here: Kennedy Seminars 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. Are you bringing a Guest?* Yes No Additional GuestName* Mr.Mrs.MissMs.Dr.Prof.Rev. 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*FemaleMalePrefer not to sayDate of Birth* Month Day Year Passport Number* Passport Country* Passport Issue Date* Month Day Year Passport Expiration* Month Day Year 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 NameThis field is for validation purposes and should be left unchanged.
