EmailMe Form - PAIN MANAGEMENT IN THE OPIOID CRISIS CRUISE

To Register for the Pain Management Cruise Seminar onboard Celebrity Cruises, Celebrity Equinox, Please complete the following information and SUBMIT.

You will receive an email confirmation that your registration has been received within 24 hrs of submission.

*If you do not receive your registration confirmation within 24 hours, please email us at info@thecruiseacademy.com to ensure we have received your form.

Your initial invoice will be emailed to you within 2 weeks of registration.

Please do not book any airfare until you receive your initial invoice with instructions.

Thank You! We look forward to meeting you onboard.

Amanda Darling, RN

The Cruise Academy

GUEST 1 - Title *

GUEST 1 - LEGAL NAME AS IT APPEARS ON YOUR PASSPORT *

First Last Suffix

Please enter your FIRST and LAST name as it appears on your government issued Passport or ID; middle names are NOT needed unless they are part of your legal first name

Country of Citizenship *

Professional Credentials (*attendees only)

Guest 1 - I will attend the seminar onboard *

Yes, I will attend

No, I am just cruising

Date of Birth *

MM / DD / YYYY

Address *

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

Home Phone

### - ### - ####

Cell Phone *

### - ### - ####

Cell phone is required in the event we need to contact you when you are traveling to the seminar.

What Shift do you work?

Days

Evenings

Nights

By letting us know what shift you work, we will know when NOT to contact you.

Primary Email *

Please ensure that you provide an email other than your work email which may bounce our emails as spam

Secondary or Work Email

Are you a Cruise Academy Past Guest? *

Yes

No

Are you a Celebrity Cruises Past Guest? *

Yes

No

Past Guest Number:

Do you have a Passport? Passports are Recommended for ALL Cruises. *

I have a Passport

I Do Not have a Passport, I will get a passport

Payment Info Guest One *

Number *

Re-type CC Number *

Exp Date *

MM / YY

Do you have any Special Needs?

Guest 1 Travel Insurance *

Yes, I would like Travel Insurance

NO, I decline Travel Insurance Against TCA's advice

If you choose Yes, if policy will cost >$150, we will email you first before processing.

GUEST 2 INFORMATION

Will Guest 2 attend the seminar onboard? *

Yes, Guest 2 will attend

No, Guest 2 will NOT attend

Solo Cruiser, No Guest 2

Guest 2 - Has Already Registered

Guest 2 - Will Register Soon (*Note - Reservations will not be processed until both registrations are received).

Guest 2 - Title

GUEST 2 - LEGAL NAME AS IT APPEARS ON YOUR PASSPORT

First Last Suffix

Please enter your FIRST and LAST name as it appears on your government issued Passport or ID; middle names are NOT needed unless they are part of your legal first name

Country of Citizenship

Professional Credentials (*attendees only)

Guest 2 - Date of Birth

MM / DD / YYYY

Guest 2 Address - Leave Blank if Same as Guest 1 Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home Phone

### - ### - ####

Cell Phone

### - ### - ####

Cell Phone is Required in the Event we need to contact you as you are traveling to the seminar.

What Shift do you work?

Days

Evenings

Nights

By letting us know what shift you work, we will know when NOT to contact you.

Main Email

Work or Secondary Email

Are you a Cruise Academy Past Guest?

Yes

No

Are you a Celebrity Cruises Past Guest?

Yes

No

Past Guest Number:

Do you have a Passport? Passports are Recommended for ALL cruises

I have a Passport

I Do Not have a Passport, I will get a Passport

Payment Info Guest Two

Number

Re-type CC Number

Exp Date

MM / YY

Do you have any Special Needs?

Guest 2 Travel Insurance

Yes, I would like Travel Insurance

NO, I decline Travel Insurance Against TCA's advice

If you choose Yes, if policy will cost >$150, we will email you first before processing.

Guest 3 Legal Name as on Passport

First Last

Date of Birth

MM / DD / YYYY

Guest 4 Legal Name as on Passport

First Last

Date of Birth

MM / DD / YYYY

What Type of Cabin would you like? *PRICES ARE DOUBLE OCCUPANCY UNLESS OTHERWISE NOTED *

INSIDE CABIN - SOLD OUT - PRICE AS QUOTED

Oceanview Cabin - SOLD OUT - PRICE AS QUOTED

Oceanview Balcony - SOLD OUT - PRICE AS QUOTED

Single Travelers MUST choose one of the Single Occupancy Options; other prices are based on Double Occupancy of a Cabin Only

Guests 1 and 2 are entitled to 2 perks for FREE. Please choose your 1st perk (both guests must choose same perk) - RECOMMEND BEV PKG AND OBC OR WIFI. *

Classic Beverage Package *Best Value (includes alcohol, soda, bottled water) $400pp value

$300 onboard credit per cabin ($150pp guests 1 & 2)

Unlimited Internet Package

Prepaid Gratuities (least recommended - Value is $101.50 - better to choose OBC)

Choose 2nd Free Perk for Guests 1 and 2: (both guests must choose same perk) *

Classic Beverage Package *Best Value (includes alcohol, soda, bottled water) $400pp value

$300 onboard credit per cabin ($150pp guests 1 & 2)

Unlimited Internet Package

Prepaid Gratuities (least recommended)

Bed Configuration *

1 Queen

2 Twins

What Time Dining Would You Like? *

Early with the Group (6pm; will be seated w/ other nurses)

Late with the Group (8pm; will be seated w/ other nurses)

Anytime Dining (will not be seated w/ other nurses and will have less group interaction)

Would You Like to Pre-pay your Tips / Gratuities? *

YES, Please add to my reservation

NO, will pay onboard

Friends or Family wish to cruise too? Have them book with us to secure our group rates and perks. They do NOT need to be attending the seminar to book their cruise with us. *

I understand that my friends and family can book with The Cruise Academy

Are You Traveling w/ anyone else who you would like to be seated near for dinner, or have your cabin near if possible? Please indicate name(s) in comments

PRICING INFORMATION

*Please Note, Prices INCLUDE ALL TAXES & FEES, but DO NOT INCLUDE TIPS, GRATUITIES, AIRFARE or TRAVEL INSURANCE.

* If Crude oil prices rise above $70 per barrel, the cruiseline may institute a fuel surcharge.

**Additionally, if you do not have a roommate; single prices listed are listed above for a single in a cabin. Cruise fees for single travelers are 150% to 200% of the normal rate. These prices are set by the cruiseline; we have no control over their policies.

Payment Instructions: *

FULL CRUISE PAYMENT DUE

Seminar Payment *

Seminar Fee is charged 30 days after registration for those attending the onboard seminar.

Terms and Conditions:

*I realize that if I have declined travel insurance, I UNDERSTAND THAT IF I NEED TO CANCEL OR INTERRUPT MY TRIP, OR IF I AM INJURED DURING THE COURSE OF MY TRIP THE CRUISE ACADEMY OR PALM COAST TRAVEL IS NOT & WILL NOT BE HELD LIABLE.

**ADDITIONALLY, IF MY TRIP IS AFFECTED BY INCLEMENT WEATHER OF ANY KIND, AND I MISS THE SHIP COMPLETELY OR INCUR EXPENSES TO CATCH UP TO THE SHIP, AND DID NOT PURCHASE INSURANCE, I AM LIABLE FOR THOSE CHARGES, NOT ENTITLED TO ANY REFUNDS AND DO NOT HOLD THE CRUISE ACADEMY OR PALM COAST TRAVEL RESPONSIBLE.

*Also, in the event of acts of war, ship malfunction, ship accident, change of scheduled ports or itinerary changes beyond our control, by submitting this form, you agree to hold harmless The Cruise Academy & Palm Coast Travel.

*BY SUBMITTING THIS FORM I RELEASE THE CRUISE ACADEMY & PALM COAST TRAVEL FROM ANY RESPONSIBILITY FOR THE ABOVE.

*If you have chosen the travel insurance option, we will add the travel insurance to your package.

*By submitting this form, I understand & have read the cancellation policy listed at http://www.cruiseacademyseminars.com/9.html

Terms and Conditions *

*By submitting this form I/We agree to the terms and conditions, to allow the credit card(s) to be charged for the deposits as noted above, and any cancellation fees should I cancel my attendance.

Airport Transfers

Arrival Fort Lauderdale

Departure from Fort Lauderdale

Round-trip Transfers Fort Lauderdale

Not sure, will let you know later

Airport I am Flying From:

Attendees Submitting Separate Forms:

Roommate will register later (please indicate name in comments)

I do not have a roommate; traveling solo at above price

Help me find a roommate

Questions or Comments:

PASSPORT DISCLAIMER:

PASSPORT IS HIGHLY RECOMMENDED FOR THIS CRUISE.

*Please be advised, that PASSPORTS or a PASSPORT CARD are required for INTERNATIONAL TRAVEL, including air, land & sea, as of JUNE, 2009.

*Depending on the cruise itinerary, your cruise may be a 'closed loop' cruise and not require a passport; check w/ your agent.

*If you choose to travel without a passport, please be advised, that if there were any emergency whether it be personal medical emergency or medical emergency of someone at home, you WOULD NOT be able to easily fly home if you are traveling without a passport because Passports are required for all international air travel.

*IF you travel without a valid passport, you assume responsibility for your actions and the potential risk that you are taking.

*By submitting this form, you agree to release The Cruise Academy and Palm Coast Travel from any responsibility should you travel without a valid passport.

DOCUMENT POLICY:

Please be advised that we send information via email only; you will not receive any paperwork via U.S. Postal Service Mail. You will receive your initial confirmation within 24 hours of submitting this registration.

*ALL invoices, important information about your upcoming cruise & your FINAL CRUISE DOCUMENTS will be sent via email. It is very important that you supply us with a working email that you actually check at least every few weeks.

*Please add info@thecruiseacademy to your address book or safe list so that our emails do not end up in your spam or bulk mail.

*If you do not receive the important information we send out via email, you will be missing out on very important information.

*Final Cruise Documents are sent VIA EMAIL approx. 30 days prior to the cruise sail date. The cruiselines no longer send paper tickets; only 'e-documents' much like the airlines.

*Call us at 1-800-688-9385 with any questions.

I Understand the Document Policy *

Yes, I understand the document policy

I understand the TCA policies above, including the Cancellation Policy Above, Travel Insurance Recommendation, Passport Policy & Document Policy *

Yes, I understand

How Did You Hear About Us? *