2004 Summer Medical Institute Commitment Form

Name:___________________________

E-mail Address: __________________________________

Phone Number: _______________________________

Health Insurance Provider: ______________________________

I, _______________________, understand that by signing this commitment form, I am reserving a place for myself on the SMI 2004 South Africa trip. I understand the following rules and regulations and agree to all terms below:

- The $400 deposit is non-refundable and is due no

later than February 6,2004. If I do not have this money in by Feb.6, I understand I will not have a reservation for SMI 2004.

- I am responsible for the full cost of the trip (airfare, ground costs, etc.). If my fund raising support doesn’t fully pay for the trip, I understand that I am responsible for the remainder.

- I understand that the full amount of the trip must be paid by April 5, 2004 or I will not be bought a plane ticket for SMI 2004 resulting in not going on the trip.

- If I cancel my reservation at any time, no money will be refunded.

****The money goes to pay for Kruger National Park accommodations and safaris, hotel accommodations, food that the Palmers have to buy in advance, airline tickets, and buses. These things have to be paid in advance and are non-refundable so if you cancel, we can’t get the money back.

- I understand that the full amount of the trip must be paid by April 5^th, 2004.

____________________________________ ____________

SIGNATURE DATE