Robert R. Schneider


Ukraine Tour Registration Form

To register for the tour, each member of the tour should complete a "Registration Form" and return it, along with a check or money order for the down payment, made out to SCHNEIDER TOURS. Please feel free to make copies of this form if you need additional copies.

Name ____________________________________________________________________(Married women please include maiden name.)

Street address: ________________________________________City_______________________________State______Zip __________

Home phone :__________________________ Work phone : ________________________

E-mail ________________________________________Fax__________________________Date of birth:____________

Hotel room rates are based on double occupancy. Name of traveling companion:________________________________________________

If you are traveling as a single, circle: Single

Please list any health restrictions or concerns:____________________________________________________________________________

Please list the Black Sea ancestral villages most important for you to visit, indicating your first and second choice. Our tour coordinators will try to include your ancestral villages on the itinerary, however, it may not be possible to include all your villages. A private tour could also be arranged to visit those villages that could not be included in the itinerary; for example the Gluckstal villages in Moldova. If you know the location of your ancestral villages, please list them with the district in which they were located (since many villages of the same name are found in more than one district.)

Beresan District: ___________________________________________________________________________________________________________

Bessarabian and Dobruscha Areas: ____________________________________________________________________________________________

Liebental District:_________________________________________________________________________________________________________

Hoffnungstal Odessa Parish: _________________________________________________________________________________________________

Kutschurgan Colonies: _______________________________________________________________________________________________________

Crimean and Taurien area: ___________________________________________________________________________________________________

Gluckstal Colonies: _________________________________________________________________________________________________________
(Gluckstal, Neudorf, Bergdorf, and Kassel are Gluckstal colonies. Kassel is located in Ukraine, but will be visited as part of the Gluckstal colonies. A seperate trip is required to visit the colonies in Moldova.)

NOTICE: By registering for the tour, you agree to abide by the terms and conditions of the tour as stated in SCHNEIDER TOUR INFORMATION AND ITINERARY. You agree to accept the services contracted; and you agree to give your consent to receiving emergency medical treatment as deemed advisable by tour officials due to the incapacity of the tour member to give consent as a result of injury, accident or illness.


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