Event Registration

Second Gesundheit Clown Tour in Georgia and Armenia

Personal Information

Number of Attendees: First Name: Last Name: Nickname Preferred Gender Pronoun: Birth Date: / /

Contact Information

Country: Address: City: State/Province: Zip: - Email: Cell Phone

Additional Information

Please write a short description of yourself Have you done volunteer and social work in the past? How about as a clown? Please describe. Do you have any Health Concerns? Or Special Dietary Restrictions? Please include any Food Allergies. Would you be comfortable rooming with someone of another gender? Will you be requesting a single room?

Yes

Dietary Preference (choose 1 option and mention exceptions/allergies above) Languages Spoken What is the best way and time to reach you? How did you hear about the Japan Clown Trip?

Emergency Contact Information

Emergency Contact Name Emergency Contact Relationship Emergency Contact Phone Number Emergency Contact Email

Passport Information

Current Passport Status Passport Number Country that Issued your Passport Passport Expiration Date

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Neon CRM by Neon One

Patch Adams MD & Gesundheit Institute, P.O. Box 307, Urbana, IL 61803