Rome Trip Registration Registration for Pilgrimage to Central Italy Florence • Siena • Assisi • Cascia • Rome October 7–17 Name as in passport(Required) First Middle Last Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Emergency Contact Name(Required) First Last Emergency Contact Phone Number(Required)Any medical conditions (if none please write NONE)(Required)Do you have any problems walking long distances? (5 miles or more)(Required) Yes No Other Do you have a valid US Passport that will not expire within 6 months of the travel time?(Required) Yes No Applying for a passport Non-Fundable Deposit(Required) Non-Refundable Deposit of $1000 (full due 2 months prior to trip)(remaining balance by check or cash preferred) If you would like to help the church in paying for the 3.5% processing fees please click YES below YES CC Processing Fees Price: $0.00 Total Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name Consent(Required) I understand and agree to commit to paying Chaldean Catholic Diocese $1,000 as a nonrefundable deposit to secure my spot, and eventually the rest of the payment to attend this pilgrimage. Δ
