Registration for Ireland Tour with Phil Cousineau

September 18 – 28, 2017

Please submit a separate form for each traveler

After you complete and submit this form, you will automatically be re-directed to the Payment Page, with instructions on how to pay by check, money order, credit or debit card. A non-refundable deposit of $500 ($525 credit card) is required to reserve your space on this tour.

NOTE: The name you enter below must be exactly as it appears or will appear on your passport. If you do not have a passport at this time, please submit this form now and provide BMSJ with your passport information after you receive your passport. Your passport expiry date should be more than six months after the ending date of this tour.

First Name (required)

Middle Name (if applicable)

Last Name (required)

Passport Number

Country of Issue (required)

Passport Issue date

Passport Expiry date

Date of Birth (required)

Country of Birth (required)

Mailing Address (required)

City (required)

State/Province (required)

ZIP/Postal Code (required)

Telephone (required)

Your Email (required)

I am: FemaleMale

I have physical limitations that require special attention. I am entering details in the "Optional Message" area below. (Most situations can be accommodated, but we must know beforehand in order to make arrangements, and there may be additional costs.)

I require a special diet and am entering details in the "Optional Message" area below.

(Required) I am requesting:

(Optional) My roommate will be:
I do not have a roommate and I understand Body Mind Spirit Journeys will try to match me with a suitable roommate.

Optional Message

Body Mind Spirit Journeys highly recommends the purchase of Trip Cancellation Insurance, and our preferred Insurance provider is Allianz.

(Required) I understand and accept the Terms and Conditions for this program. I understand some or all payments made may be forfeited, based on my cancellation of this program as detailed within the Terms and Conditions linked from this reservation form. Should this trip be cancelled by Body Mind Spirit Journeys, all payments received will be refunded.
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