MSU Mississippi Dental, Peru, May 2022 - Flight Reservation Form

First name*

Exactly how it appears on your passport

Middle name

Exactly how it appears on your passport

Last name*

Exactly how it appears on your passport

Date of birth*

Sex*

Male
Female

Passport issue country*

From which country is your passport (e.g., USA)? *Note: if you do not have an updated passport, still fill out the flight form and simply put “in process” for your passport number and an approximate date for your new passport expiration date. Once you receive your new passport, please update your Empowered application/volunteer sign-up form with your new passport number, expiration date, and your full name as it appears on your new passport and email your Team Development Coordinator to let them know that it has been updated.

Passport number*

Passport expiration date*

Phone number*

E.g., (555) 555-5555

Email address*

E.g., yourname@gmail.com

USA airport from which you wish to depart*

JAN
BHM
I wish to depart from an airport different than the group (see below)

Please put all that apply (e.g., JAN, BHM); group will be departing from JAN, BHM.

Departure airport preference different than group (only complete if applicable)

If you wish to depart from an airport different from the group, please indicate so below with your preferred airport(s) and note/comment

USA airport at which you wish to arrive*

JAN
BHM
I wish to arrive at an airport different than the group (see below)

Please put all that apply (e.g., JAN, BHM); group will be arriving to JAN, BHM.

Arrival airport preference different than group (only complete if applicable)

If you wish to arrive at an airport different from the group, please indicate so below with your preferred airport(s) and note/comment

VAW Outreach trip dates*

I wish to travel with my team on our trip dates (May 31-Jun 14)
I wish to travel on DIFFERENT dates than my team (see below)

The trip dates for your team are May 31- Jun 14. If you wish to travel on different dates, please see below.

Trip dates preference different than group (only complete if applicable)

If you wish to depart from and/or arrive on dates different from the group, please indicate so below with your preferred date(s) and note/comment

Special meal request*

Certain airlines offer special meals for those with dietary restrictions. We will do our best to communicate your dietary needs with the airline. However, we cannot guarantee it and you should double check directly with the airline at least 48 hours prior to departure.

Frequent flyer number (if applicable)

Please include the airline(s) name(s) and frequent flyer(s) number(s) you have, if applicable.

Additional comments & notes

Any information you would like us to know when booking your flight (eg, you will not be traveling with the group)

In-country airport transportation cost if not on the group flight*

I understand and agree that if I choose not to fly with my team, I will be responsible for the cost of my own transportation to/from the airport in my host country

It is important to understand that if you are not on the same flight as the group arriving and/or departing from the host country, you will be responsible for your own transportation to/from the airport. We are happy to help you set up transportation with a reliable taxi driver, but you will be responsible for covering that cost. Approximate costs for each country are listed below in USD and are one way: Cambodia: $15 Dominican Republic: $50 Guatemala: $120 Panama: $50 Peru: $15 Vietnam: $100

VAW Flight Terms and Conditions*

I have read and agree to the VAW Flight Terms and Conditions.

VAW Flight Terms and Conditions: I understand that the information I fill out here will be sent directly to the travel agent. I understand that if there is a mistake on this form, I will be responsible for covering the charges for any changes required once my ticket has been issued. I understand that if I request an airport, I will be scheduled to/from that airport regardless of cost and I will be responsible for covering that cost. I understand that if I do not arrive/depart on the group flight, I will be responsible for paying for the cost of my transportation to/from the airport in the host country. I acknowledge and agree to these terms and conditions.

Attestation*

I assert that the information I have provided in this application is true and accurate.

MSU Mississippi Dental, Peru, May 2022 -- Flight Reservation Form

Flight Reservation Form

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Application open in September 2023