191 Castor Street, P.O.

337, Russell, Ontario K4R 1E1

24 hour service: 1-800-718-1785 or (613) 445-3682 Fax: (613) 445-2682
Web Site: www.perspectives-edu.com

2010 REGISTRATION FORM

DESTINATIONS

 QUEBEC CITY QUEBEC CITY & TADOUSSAC MONTREAL OTTAWA

 KINGSTON TORONTO  NIAGARA FALLS SUDBURY OTHER______________________
Name: _________________________________________________
Personal Address: ________________________________________
City/Town: Postal Code: _____________
Tel.(Res.): ________________________________________________
School Chippewa Secondary School________________________
Date of Trip: April 15-16, 2010 – Ottawa ___________________
In case of emergency, name: _________________________________
Tel.(emergency): _________________________________________
Date of Birth: M F 
month/day/year
Health Card #: ___________________________________________
Original card preferred: photocopy accepted in
hospitals but not clinics
DRUG AND AL COHOL POLI C Y
Under no conditions or circumstances will drugs or alcohol be
permitted.
Any students found abusing this rule or causing disciplinary problems
will be dismissed from the programme and sent home at the
responsibility and expense of the parents or guardian .
CONSENT FOR M
I acknowledge by my signature that I have read, understand and
accept the contents and effects of the trip cancellation insurance
liabilities, drug and alcohol policies of Perspectives Eduscho Ltd.
_____________________________________________
Parent's Signature (or Guardian)

_____________________________________________
Student's Signature

Please complete and return with your cheque made payable

to: Perspectives
** Print date of travel, name of student & school on all cheques **
$40.00 administrative fee will be applied for all NSF cheques
PERSPECTIVES CANCELLATION RBC TRAVEL INSURANCE
POLICY Medical, Cancellation & Interruption
Since refunds are not possible after the 90 day deadline,  I wish to purchase trip insurance
Perspectives is pleased to offer to individuals, families and
students the opportunity to purchase Cancellation, Interruption ____________________________________
and Medical insurance package through "RBC Travel
Insurance". Parent or Guardian Signature
TRIP PRICE # OF DAYS AGE: 0-17 Yrs
 I do not wish to purchase trip insurance
$0-$400 1 to 3 days $36.00
4 to 6 days $40.00 I, undersigned, will not hold my travel agent or travel agency
1 to 3 days $38.00 responsible for any expenses incurred as a result of my refusal
$401-$500 4 to 6 days $42.00 to purchase trip cancellation & interruption insurance
$501-$600 1 to 3 days $40.00
4 to 6 days $45.00 ____________________________________
1 to 3 days $43.00
$601-$700 4 to 6 days $48.00 Parent or Guardian Signature
1 to 3 days $50.00
$701-$1000 4 to 6 days $56.00 Plea se con su lt th e “R B C Insu ran c e ”
web site
Cheque for insurance made for informa tio n on the in su ra n ce polic y
payable to WWW . RBCINSURANCE . COM

« PERSPECTIVES » T EL : 1- 800- 387 - 4357

must acco mp an y the initia l depo sit

TICO LICENCE#: 4259719 GST #: R121046684