Making the Road

Making the Road Travel Seminar to Cuba, August 2017.

Short application form for basic information. Please note there will be another form with questions requiring longer answers.

Please fill out the entire form and submit electronically as soon as possible. The final deadline for submission of this form is June 19, 2017.

You should receive an email message from Mailchimp asking you to "confirm your subscription." This is needed to confirm that your email address is correct.

Fill in as many blanks as you can. If there are some required fields you cannot fill in now, please just enter "to come." You will be asked for this additional information at a later time.

Also remember to complete the long-form application.

Please address any questions about form completion to the database manager William Minter (email: wminter@gmail.com; home/office phone - 202-234-0338).

* indicates required

Email Address *

Required!

First (and middle) Name *

Required. Enter as on your passport.

Last Name *

Required. Enter as on your passport.

Preferred name (e.g., nickname)

What you want people on the trip to call you.

Preferred phone number *

Required! We need to be able to contact you.

Street Address *

City or town of residence *

State or province of residence *

Zip code of residence *

Country of residence *

Age *

Over 35
25 to 35
15 to 24

Gender *

Birthplace *

City or town, country

Passport (country,number,issue & expiration date) *

Fill in when you are definite about participating in the trip.

Birthdate *

in format mm/dd/yyyy

Emergency Contact *

Please enter name, email, phone number and other details needed for contact.

Preferred format

HTML Plain-text

MTR: Cuba 2017