Delegation Leader Information Form

Delegation Leader Information
Delegation Leader Information
Name*

PrefixPreferred First NameMiddle InitialLast Name
Gender (with which most identified)
Mailing Address*

Street Address (If PO Box, please also list street address)

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Phone Number*

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Email*
example@example.com
Emergency Contact

Full NamePhone Number
Citizen Ambassador Program Covid-19 requirements

The Citizen Ambassador Program requires all participants to be fully vaccinated prior to travel as a condition of participation. Additional testing may be required for entry into the host country, we will notify you of the specific requirements, no later than 30 day prior to departure, or as a countries requirements are updated. If you have questions regarding the Covid-19 travel requirements, please contact our office.
Covid-19 Travel Requirements

I am fully vaccinateI am not fully vaccinated, however will be fully vaccinated prior to departure
Passport information- Information may be provided at a later date

Passport Required-All delegates must have a valid passport. The passport must be valid for at least six months beyond the completion of the delegation/extension/additional travel. It is recommended that passports have a minimum of 3 blank pages.
Legal Name (as it appears on your passport)

Last NameMiddle NameFirst Name
Country of birth
Citizenship
Date of birth

MonthDayYear
Passport Number
Passport Expiration Date

MonthDayYear
Delegation Leader Rooming Information

I will be traveling alone ( a single room is included for the Delegation Leader)I wish to room with:___________________________________________________________
I/we prefer

Two bedsOne bed
I/ we prefer a

Smoking roomNon-smoking roomNo preference
My traveling companion is a...

Professional delegateGuest (Participating guests must be at least 18 years of age at time of travel)Under 18 years old (may not participate in the professional program, will require adult accompanying guest)
Name

PrefixPreferred First NameMiddle InitialLast Name
Gender (with which most identified)
Mailing Address (If different than the Delegation Leader)

Street Address (If PO Box, please also list street address)

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Occupation

TitleEmployer
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Email
example@example.com
Passport information- Information may be provided at a later date

Passport Required-All delegates/guests must have a valid passport. The passport must be valid for at least six months beyond the completion of the delegation/extension/additional travel. It is recommended that passports have a minimum of 3 blank pages.
Legal Name (as it appears on your passport)

Last NameMiddle NameFirst Name
Gender
Country of birth
Citizenship
Date of birth

MonthDayYear
Passport Number
Passport Expiration Date

MonthDayYear
Emergency Contact

Full NamePhone Number
Physical Accommodations

Accommodations for special needs will be made to the best of our abilities. Many of the countries with which the Citizen Ambassador Program conducts professional exchanges may not be equipped to meet your needs. We will make every effort to support requirements for travel. If you require a supportive travel companion, please contact our office to enroll your support companion.
Please list any special need requirement to participate in the Citizen Ambassador Program
Should be Empty:

Delegation Leader Information

Delegation Leader Information

Citizen Ambassador Program Covid-19 requirements

Passport information- Information may be provided at a later date

Passport information- Information may be provided at a later date

Physical Accommodations