Name *

First Name

Last Name

Do you have/have you ever had... *

Check all that apply

Asthma

Heart disease

Heart attack

Blood pressure issues

Chronic illness

Spinal surgery

Knee surgery/replacement

Allergies

None

I am purchasing trip insurance *

because we all know sometimes things don't go as planned

YES

NO, I am opting out but understand YHG recommends trip insurance

I agree to pay a 25 percent deposit to reserve my spot *

I agree to pay the remaining balance 45 days prior to my trip departure *