CWM 2022 Registration

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2022 Cruise With A Mission Registration

Come sail with us to the Eastern Caribbean from December 15-22, 2022!

Spend a sun-soaked week on this Caribbean cruise. Go back in time on Grand Turk, wander San Juan's historic streets, hike the jungled cliffs of St. Thomas, enjoy beaches at Half Moon Cay.

We will be sailing from Fort Lauderdale, Florida.

Before you begin, please have the following available:

A valid email address
Primary care physician contact information
Medical insurance information
Medication list (if applicable) and immunization history (if available)
Major credit card

Personal Information

Name*

First Name

Last Name

Gender*

Male Female

Date of Birth*

Email*

Phone*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Would you like to add your name to the on-board directory?*

Yes No

Holland America Mariner Number (CCN)

Emergency Contact Information

Emergency Contact Name*

First Name

Last Name

Personal Relationship*

Emergency Contact Phone Number*

Emergency Contact Email Address*

Physician / Insurance Information

Primary Care Physician*

Office/Clinic Name*

Office Phone Number*

Do you have health insurance?*

Yes No

Insurance Carrier Name

Insurance Carrier Phone (If Known)

Medical Information

Please indicate which of the following vaccines you have received:

All DPT/OPV/MMR vaccinations as a child Last DT and MMR booster within 10 years Last OPV booster within 6 years Hepatitis B immunization sequence (3 shots) New (since 1995) Hepatitis A immunization (1 or 2 shots)

Please list all important medical diagnoses and any previous surgeries or major illnesses:

Please list all known food/medication allergies:

Please list all medication(s) to be taken daily or occasionally during the trip - Name/Dosage/Times Taken:

Blood Type (If Known)

Payment Information

Early Bird Price $

Regular Price $

Labor Day Discount $

Late Price $

Total $

Date/Time

Name on Credit Card*

First Name

Last Name

Purchaser Phone Number*

Purchaser Email Address*

Billing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Credit Card*

Contact Information

Name*

First Name

Last Name

Email*

Home Phone*

Cell Phone

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Which church do you attend?*

Who is your pastor?*

Age (Must be 16+)*

Personal Information

Emergency Contact Information

Physician / Insurance Information

Medical Information

Mission Participation

Other Information

Payment Information

Contact Information