Brown Girl Book Tour Author Travel Form

Authorization and Consent: I hereby authorize the Brown Girl Book Tour organizers to use this information for travel arrangements and in case of any emergency. I understand that this information will be kept confidential and only shared with necessary personnel for insurance and emergency purposes.

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Full Name *

First

Last

Date of Birth

EIN

Gender

• Male
• Female

Home Address:

Phone Number

Email *

Tour Cities Attending:

• Wilmington, Delaware
• Brooklyn, New York
• Baltimore, Maryland
• Virginia Beach, Virginia
• Charlotte, North Carolina
• Atlanta, Georgia
• Miramar, Florida
• Cincinnati, Ohio
• Chicago, Illinois
• Los Angeles, California

Departure Date:

Return Date

Preferred Mode of Travel:

• Air
• Train
• Bus
• Car

Accommodation Preferences:

• Hotel
• Airbnb
• Other

Dietary Restrictions or Preferences:

Primary Emergency Contact *

First

Last

Primary Emergency Contact Relationship

Primary Emergency Contact Phone Number

Primary Emergency Contact Email *

Secondary Emergency Contact *

First

Last

Secondary Emergency Contact Relationship

Secondary Emergency Contact Phone Number

Secondary Emergency Contact Email *

Health Insurance Provider:

Policy Number:

Group Number (if applicable):

Primary Care Physician:

EIN Gender Contact

Medical Conditions or Allergies:

Medications:

Any Special Medical Needs:

21. Preferred Hospital or Medical Facility (if applicable):

Submit