Registration Form Peru 2010
Please print your name, address, home and cell phone, email address and emergency contact information.
Include with your deposit. Thank you.

Name ____________________________________________________________________________

Address __________________________________________________________________________

City __________________________________Sate: ____________ ZIP ______________________

Home Tel. # __________________________ Work # _____________________________________

Cell # ________________________________ e-mail: ______________________________________

Website _______________________________Passport Country of issuance_____________________

Passport #______________________ Date of issuance _________ Date of Expiration_____________

Name on passport: _____________________________________ (Needed for arrangements in Peru)


Emergency contact: Name __________________________ Address _____________________________

City: _________________________ Sate: ______ Zip code: ________ Telephone # ________________

Email Address: _______________________________________________ for easy contact while traveling.
There will be a contact person in the U.S. who will send updates to your contact during our journey.

I am signing up for:   Peru Journey April 14 - 24, 2010
Location: Cusco region, (Sacred Valley and Machu Picchu)
Contact Rev. Nancy at: or call 714-739-5819 (leave message if we do not pick up).

Pre-Registration required. Make $500.00 deposit ASAP or by January 15, 2010,
or full payment $2,650.00 (double occupancy) to: Nancy Kimes. Single supplement add $390.00
(3% additional charge for credit card payment / paypal payment)

Amount enclosed $______________ Check#_____________ (Please do not mail cash).

Mail to:
Nancy Kimes, 5712 Conifer Drive, La Palma, Ca. 90623 (714) 739-5819

Full payment with $150.00 discount due by 10th of March, 60 days prior to departure for Lima, Peru.

Otherwise, full payment of $2,650.00 (double occupancy) due 30 days prior to departure for Lima, Peru.

I am ALSO interested in signing up for the 6-Day Extension Tour - Check here _____
You will be sent the Extension Tour intinerary which will include travel to the Reed Islands Lake Titicaca - April 24-29.
Additional moneys (to be determined) will be required for this extension.