Name* First Last Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Other Family Members/Friends Participating in TripPlease check the following boxes to acknowledge you understand and are willing to cooperate with these additional responsibilities:* I understand that participation on this trip is first-come-first-serve and that this registration does not GUARANTEE that I have a spot. I understand I will receive an email shortly with my status. I acknowledge that I am responsible for purchasing my own airfare and for obtaining a valid passport and any necessary vaccinations and medications before the trip. I acknowledge that I will need to sign and return a liability waver for the trip. I acknowledge that trip volunteers will be interacting with children; therefore I will provide Project Left Behind with information needed to run a standard background check for security reasons. I acknowledge that a non-refundable deposit of $500 must be received by the ESCAPE2016 team within 7 business days in order to hold my spot. (No deposit is required at this time. If you do secure a spot on the trip, payment directions will be emailed with your confirmation.) I acknowledge and understand that all rooms will be double occupancy. If single occupancy is an option and I wish to have such, an additional fee of $500 will be charged. This iframe contains the logic required to handle Ajax powered Gravity Forms.