EmailMe Form - Day Trip to San Francisco: Gold Rush Days

Name *

Prefix First Middle Last Suffix

What is your birth date: *

MM / DD / YYYY

Address *

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

Email *

Confirm

Mobile Phone

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

Home Phone *

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

Please tell us which phone to use when we need to call you? *

Home Phone

Mobile Phone

My Home Phone is my Mobile Phone

Special Needs:

Please let us know if there is any special needs just as dietary, need to seat in front seat, wheelchair. Please note that we will not be allowing scooters on board, only scooters that are under 50 lbs and can be stored under the bus. We will need prior approval for both scooters or wheelchair to assure we can accommodate.

TRAVEL COMPANION INFORMATION

Will you be traveling with a companion? *

Yes, I will be traveling with my partner

Yes, but they will submit their own reservation

No

Partners Name

Prefix First Middle Last Suffix

Partner's birth date:

MM / DD / YYYY

Partner's Email

If you wish them to get a copy of emails and invoices.

Partner's Phone

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

Partner's Phone

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

Partner's Special Needs:

Please let us know if there is any special needs just as dietary, need to seat in front seat, wheelchair. Please note that we will not be allowing scooters on board, only scooters that are under 50 lbs and can be stored under the bus. We will need prior approval for both scooters or wheelchair to assure we can accommodate.

HOW DID YOU HEAR ABOUT THIS TOUR? *

Emergency Contact Person -- Someone not traveling with you.

First Last

Relationship

Emergency Contact Phone

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

Number of Tickets *

1 Ticket $120

2 Tickets $240

Please charge my credit card for the refundable deposits - Terms and conditions apply.

Check Form of Payment-If you would like to pay by check, a check can be dropped off at 840 6th Street, Los Banos, CA 93635. Please make the check payable to: DREAM VACATIONS and PUT GOLD RUSH DAYS IN MEMO. Complete this registration form and hit submit to complete registration. *

I wish to pay by Check

I wish to pay by Credit Card