Registration Form Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email PhoneHave you ever traveled to Africa? If so, where?* If you have traveled to Africa previously, was it with a tour or on your own? Please indicate which Ethnic Group your DNA has been traced to (only complete if you know) Please indicate how many people will be traveling with you. Are you interested in receiving a name from your Ethnic Group, taking part in a Naming Ceremony in this country? Yes No Are you interested in joining our mailing list to receive information about future trips and events? Yes No Roots to Glory Tour Registration*Deposit Required / Refundable within 30 days of the initial deposit only. After 30 days, there will be no refunds!! Benin ($500 Deposit Required / Refundable within 30 days of the initial deposit only) + Square processing fee = $515.24 Cameroon ($500 Deposit Required/Refundable within 30 days of the initial deposit only) + Square processing fee = $515.24 Cote D’Ivoire ($500 Deposit Required/Refundable within 30 days of the initial deposit only) + Square processing fee = $515.24 Ethiopia ($500 Deposit Required/Refundable within 30 days of the initial deposit only) + PayPal processing fee = $515.24 Ghana ($500 Deposit Required/Refundable within 30 days of initial deposit only) + Square processing fee = $515.24 Nigeria ($500 Deposit Required/Refundable within 30 days of the initial deposit only) + Square processing fee = $515.24 Voodoo Festival ($500 Deposit Required/Refundable within 30 days of the initial deposit only) + Square processing fee = $515.24 Sierra Leone ($500 Deposit Required/Refundable within 30 days of the initial deposit only) + Square processing fee = $515.24 test trip I understand that a Visa and Yellow Fever Vaccination is Required for entry into the country. Yes No I give Roots to Glory Tours permission to use my name and any photograph, voice, or likeness of me during the event in any promotional materials or publications. I consent to and authorize in advance such use and waive my rights of privacy I have in connection therewith.How did you hear about Roots to Glory Tours?* Facebook Website Email Ancestry DNA Travel Other Consent* I agree I disagree Waiver and Release Agreement ~~ All participants shall read this entire WAIVER and RELEASE document before submitting. I hereby agree to the following: I shall indemnify Roots to Glory Tours and hold harmless, its agents and its employees from all liability, losses, costs, claims, damages, and expenses, including attorney’s fees, arising or claimed to have risen out of personal injuries or death, or property damage or loss, sustained by me as a result of participating in a Roots to Glory Tour, however caused, including, without limitation, claimed negligence on the part of Roots to Glory Tours’ employees, volunteers, other participants, or third parties. In addition, I shall indemnify the Roots to Glory Tours, its agents and employees from all liability, losses, costs, claims, damages, and expenses, including attorney’s fees, relating to claims or injury arising from my own negligence or intentional acts during my participation in a Roots to Glory Tour(including travel to and from the activity sites). I hereby acknowledge that I am voluntarily participating in a Roots to Glory Tour. I hereby assume full responsibility for all liability and all risk of injury or loss, including death, which may result from my participating in this Program. I hereby hold harmless, release, waive, forever discharge and covenant not to bring legal action or claim against Roots to Glory Tours from any and all claims or demands I may have by reason of any accident, illness, injury or death, or damage to or loss or destruction of any property, arising or resulting directly or indirectly from my participating in the Program and occurring during such participation or any time subsequent thereto. In understand that the program leaders, the director, and the assigned staff members are acting in their respective capacities as agents of Roots to Glory Tours, not individually, and hereby waive any and all claims I may have or purport to have against the Roots to Glory Tours or against them individually for losses occasioned by any changes in travel plans, or for the failure of any of the companies providing transportation, hotel, food, tour services, or other goods or services to provide such services on a timely basis or for the failure to provide them at all. Roots to Glory Tours have the right to make cancellations, changes, or substitutions in events, the agenda, or program, assigned staff members, travel arrangements, or arrangements for other services, in the event of causes beyond its reasonable control, significantly changed conditions, or changes in the interests of the group. It is my responsibility to obtain and keep in force adequate health insurance while traveling. I understand and agree I am financially responsible for my own medical expenses. I am solely responsible for obtaining and keeping safe my personal possessions, documents, money, travel tickets (as needed), and other property. I hereby WAIVE and RELEASE Roots to Glory Tours, the program director, and the assigned staff members from any and all claims for expenses or losses of any nature and amount due to my failure to do so. I understand that I am advised to keep my medical information on my person such as wearing a medical ID bracelet. In the event of illness or injury, I hereby authorize the program director or any assigned staff member to obtain emergency or other medical treatment as he or she deems necessary, including the administration of anesthetics or other medications and surgery, and I hereby assume both any physical risk associated with and responsibility for the cost of such treatment. I am physically capable of participating in the event and I acknowledge that I alone, am solely responsible for my personal health and safety, and the personal property I bring with me. I agree to conduct myself in a safe and prudent manner while participating in the event. if, for some reason, I am having difficulty continuing with the event, I am solely responsible for making the determination either to stop or continue on with the tour and do not rely upon Roots to Glory Tours to make that determination for me. I give Roots to Glory Tours permission to use my name and any photograph, voice, or likeness of me during the event in any promotional materials or publications. I consent to and authorize in advance such use and waive my rights of privacy I have in connection therewith. I have carefully identified, reviewed and considered the risks of travel to my destination(s), including by reading the most recent relevant U.S. State Department (“DoS”), Centers for Disease Control (“CDC”), and World Health Organization (“WHO”) Travel Warning(s) available through http://travel.state.gov/, http://www.cdc.gov,http://www.who.int.html . I know conditions in my destination(s) may change rapidly and will stay informed of current events on a frequent, at least daily, basis by obtaining updated security and health information from, and registering with, the nearest U.S. Embassy or Consulate General and from the DoS, CDC and WHO websites. I will also enroll in the warden system with the U.S. Consulate(s) nearest my destination(s). If I am not a U.S. citizen, I will register with my home country’s Embassy or Consulate and get updated information from the U.S. and my home country’s Embassies or Consulates, and the DoS, CDC and WHO websites Expressly agree that the Waiver and Release is governed by the State of Maryland and is intended to be as broad and inclusive as is permitted by Maryland law. In the event that any portion of the Release is determined to be invalid, illegal or unenforceable, the validity, legality and enforceability of the remainder of the Release shall be severed from that portion determined to be invalid, illegal, or unenforceable, and shall not be affected or impaired in any way and shall continue in full legal force and effect. This General Waiver and Release of Liability of all claims is binding on my heirs, executors, administrators and, family members and any and all persons pursuing a claim on behalf of me or my estate. I HAVE READ THIS RELEASE AND I UNDERSTAND THE CONTENTS. WARNING: By agreeing to this Release, you are giving up certain legal rights, including the right to recover damages in the case of injury, death or property damage. Waiver and Release Agreement* I agree I disagree Total $0.00 Credit Card Information Add new card PhoneThis field is for validation purposes and should be left unchanged.