Ga naar de inhoud
HOME
OVER
PROJECTEN
VERHALEN
MATERIALEN
CONTACT
Main Menu
HOME
OVER
PROJECTEN
VERHALEN
MATERIALEN
CONTACT
AANMELDING MASTERPEACE WALK GEORGIA
Program: Wednesday May 27th (14:00h/2:00 PM) – Friday June 6th (7:00h/7:00 AM) 2020
Schakel JavaScript in je browser in om dit formulier in te vullen.
Formal name (as specified in passport, including all first names)
*
Voornaam
Achternaam
Given name
*
Address
*
Address Line 1
Postcode
Stad
Staat / Provincie / Regio
— Select country —
Afghanistan
Albanië
Algerije
Amerikaans Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua en Barbuda
Argentinië
Armenië
Aruba
Australië
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
België
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Sint Eustatius en Saba
Bosnia and Herzegovina
Botswana
Bouveteiland
Brazilië
British Indian Ocean Territory
Brunei Darussalam
Bulgarije
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Central African Republic
Chad
Chili
China
Christmas Island
Cocoseilanden
Colombia
Comoren
Congo
Congo (Democratic Republic of the)
Cookeilanden
Costa Rica
Cuba
Curaçao
Cyprus
Denemarken
Djibouti
Dominica
Dominican Republic
Duitsland
Ecuador
Egypte
El Salvador
Equatorial Guinea
Eritrea
Estland
Eswatini (Kingdom of)
Ethiopië
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
Frankrijk
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgië
Ghana
Gibraltar
Grenada
Griekenland
Groenland
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hongarije
IJsland
Ierland (Republiek van)
India
Indonesië
Irak
Iran (Islamitische Republiek van)
Isle of Man
Israel
Italië
Ivoorkust
Jamaica
Japan
Jersey
Jordanië
Kaaiman Eilanden
Kazakhstan
Kenia
Kiribati
Kosovo
Kroatië
Kuwait
Kyrgyzstan
Laos (Democratische Volksrepubliek)
Lesotho
Letland
Libanon
Liberia
Libië
Liechtenstein
Lithouwen
Luxemburg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marokko
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federale Staten van)
Moldavië
Monaco
Mongolië
Montenegro
Montserrat
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands, The
New Caledonia
Nicaragua
Nieuw Zeeland
Niger
Nigeria
Niue
Noord Macedonië (Republiek van)
Noord-Korea (Democratische Volksrepubliek)
Noorwegen
Norfolk Island
Northern Mariana Islands
Oekraine
Oman
Oostenrijk
Pakistan
Palau
Palestina
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Polen
Portugal
Puerto Rico
Qatar
Roemenië
Russische Federatie
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabië
Senegal
Servië
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovenië
Slowakije
Soedan
Solomon Islands
Somalia
South Georgia and the South Sandwich Islands
South Sudan
Spanje
Sri Lanka
Suriname
Svalbard en Jan Mayen
Syrian Arab Republic
Taiwan, Republiek China
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tsjechië
Tunesië
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vaticaanstad
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Zuid Afrika
Zuid-Korea (Republiek van)
Zweden
Zwitserland
Ã…land
Land
Mobile phone number (business and/or private)
*
E-mail address
*
E-mail
E-mailadres bevestigen
Date of birth
*
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
MM
1
2
3
4
5
6
7
8
9
10
11
12
YYYY
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Place of birth
*
Nationality
*
Passport number (must be valid up till 6 months after your return from Georgia)
*
Date of issue passport
*
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
MM
1
2
3
4
5
6
7
8
9
10
11
12
YYYY
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Place of issue passport
*
Portrait photo
*
Klik of sleep bestanden naar dit veld om te uploaden.
You can upload up to 2 files.
Business / Job / Education details
*
Contact details in home country in case of emergency (Name, relation, telephonenr)
*
Travel insurance company
*
Travel insurance number
*
Diet and allergies Information (if any)
*
Length in centimeters
*
Do you have any medical/healthcare licenses? (For the Dutch EHBO/BHV etc.)
*
Medical Information
*
HAVE YOU SUFFERED AN ILLNESS OR PHYSICAL INJURY RECENTLY? Please provide us with any detailed information about your medical needs. It is possible to put a list of your medication in a sealed envelope and hand it to the program management. Only to be used in case of emergency. This information will be held strictly confidential.
Please inform us about anything which is important in relation to the program and activities (incl. physical condition).
*
Can you bring your own small 2persons trekking tent?
*
Yes
No
Do you agree with the terms as mentioned below?
*
Yes I agree
By filling in this form and sending it by email I agree: 1. to pay 20% of the agreed fee of € 1850,= within 4 weeks of your application and the resuming amount at the latest on the 1st of April 2019. 2. that in case I need to cancel the trip after the 1st of May 2019, I will forfeit 100% of the agreed and paid fee. 3. that in case the Masterpeace Walk is canceled, e.g. due to less than the required number of participants or to other reasons, the amount paid is refunded. 4. Account details: Stichting MasterPeace: NL25TRIO 0390 3713 35. Additional reference: Donation MasterPeace Walk 2020 GEORGIA. 5. Dutch Income Taxes clarification: – Although Stichting Masterpeace is an ANBI, the fee amount is NOT deductible as a donation within the normal specifications of the Tax laws. – For those who would like to deduct the fee as educational costs, invoices will be sent on request and are specified without VAT. I understand that: 6. The MasterPeace Walk is not organized by a professional travel agency but by a group of volunteers in cooperation with MASTERPEACE. 7. The MasterPeace Walk and everything that comes with it is at my own risk and responsibility. I also fully appreciate the fact that there may be risks, hazards, and dangers involved in such a wildlife walk to which I would be subject. 8. I wait with my travel arrangements until the Program Management has given a final GO on the Masterpeace Walk 2020. This will be ultimately around the beginning of April 2020. Any arrangements made before the final GO date are for your own account and financial risk. 9. MasterPeace complies with the AVG Privacy Policy Guidelines. I furthermore state that: 10. I will take care of the necessary medical protection and obligated visa. 11. My general health is good and there is nothing, which renders me, unfit to undertake this walking event. 12. Together with my heirs, executors, and administrators I hereby release from any liability: MASTERPEACE EU office, MASTERPEACE GEORGIA, and the Program Management: Georgi Azariashvili , Marcella Bos, Mark Stienen and anyone involved in organizing the Peace Walk through Georgia. And from all or any claims that could accrue to me or my heirs, executors, and administrators arising out of my participation in the said MasterPeace Walk or in any related activities. I further indemnify and hold them harmless against any claims whatsoever may arise.
Website
Submit
Meld je aan voor onze nieuwsbrief!
Schakel JavaScript in je browser in om dit formulier in te vullen.
Voor- en achternaam
*
Voornaam
Achternaam
Land
Email
*
Email
Verzenden