China Heritage Tour Signup Form Print your complete name exactly as it appears on your Passport (LAST, First, Middle):(Required) First Middle Last Permanent Mailing Address, City, State, Zip:(Required) Street Address City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Phone:(Required)Cell Phone:(Required)E-Mail:(Required) Prefered Name for Tour Name Tags:(Required) Occupation:(Required) Education (if currently in school): Gender You Identify As: Date of Birth:(Required) DD slash MM slash YYYY Age at Time of Tour:(Required) Passport Number (Please include all numbers, including zeros):(Required) Expiration Date:(Required) MM slash DD slash YYYY You must have a valid United States passport for travel in China. If you do not have a passport, you must apply immediately, and notify Holt of the number as soon as you receive it.Tour T-Shirt Size:(Required) S M L XL Youth Adult Other Please indicate which information you authorize Holt International to release to members of your tour group:(Required) Your name Cell Phone Age Home State E-Mail Home Phone Please DO NOT release my information In case of emergency, please list at least one family member NOT joining the tour. Name:(Required) Relationship to you:(Required) Address:(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Phone:Home Phone:Medical Information: Please print clearly and fill out the entire form. Please attached a separate page, if needed. Holt is requesting this as part of your background information but makes no claims regarding the provision of medical services. Holt staff and tour operators are not medical professionals and are unable to offer medical intervention beyond assisting afflicted travelers to obtain care at a treatment facility. If you require either prescription or over the counter medications you should travel with a supply that exceeds your needs for the expected length of the trip. Assume that any medications available in the U.S. are unobtainable during travel. Know your insurance coverage’s conditions regarding health care while you are out of the country. This information will remain confidential. Please list current medications, including dosage & reason for taking:(Required) Please describe any known medical conditions that are currently under treatment or being monitored:(Required) Please list current ALLERGIES to medications, food, insects, or other substances:(Required)Do you have any dietary restrictions? Chinese meals typically consist of beef, fish, pork, vegetables, rice and soup. (Please be aware that alternatives may be unavailable or very difficult to arrange.)(Required)Do you have any physical limitations that may limit your participation in physical activities?(Required)Have you received any psychiatric, psychological or counseling treatment during this last year? If yes, please explain.(Required)Any other major illnesses, surgeries, treatments, hospitalizations or conditions that we should be aware of?(Required)If you have a history of any of the following conditions(Required) Arthritis Allergies Asthma Cancer Depression Diabetes Epilepsy Heart Disease High Blood Pressure Substance Abuse Psychiatric Disorder Rheumatism The Holt Heritage Tour to China will be exciting and at some times, challenging Some days may be both physically and emotionally strenuous, with long bus rides and walking in hot,humid conditions, or even rainy weather. The food and culture will be different than here in the U.S. As a foreign guest, keeping an open mind and a sense of humor will go a long way in helping manage any challenges. We look forward to guiding you through the trip and ask that you complete the questions below so we may get to know you better.Arthritis Allergies Asthma Cancer Depression Diabetes Epilepsy Heart Disease High Blood Pressure Substance Abuse Psychiatric Disorder Rheumatism Briefly list your hopes/expectations for this trip(Required)International Travel Experience? Yes/No/Where/When THIS SECTION TO BE COMPLETED BY ADOPTEES. *If you were not adopted through Holt International in the USA (Holt in China works with different US agencies), please send us copies of all adoption records you have, from both your Chinese and US adoption agencies. You can scan and Email them to us, or send us physical copies by mail to – Holt International, Attn: China Heritage Tour, 250 Country Club Rd, Eugene, OR 97401. Chinse Name (As written in your adoption documents): Adoption Case Number: Name of the orphanage you were adopted from (if applicable): City or region in China you were adopted from (if known): Do you know which agency in the United States completed your adoption? Holt International Other Agency Name*: Do you know which agency in China conducted your adoption? Holt Children’s Services Eastern Child Welfare Social Welfare Society (SWS) Korea Social Services (KSS) Other (Please list name if known) Do you have information regarding your history prior to adoption? Do you wish to conduct a birth family or background check? (For Adoptees 18+ only) Name of agency and date of any prior search: Have you had contact with your birth family? If so, how much contact have you had during your life?If possible, would you like Holt to arrange for you to: (Please note that if you change your mind after our arrival in China, it may not be possible for us to make the arrangements you desire.) Meet your former foster family? Appointment in China for a DNA Blood Draw (finger prick) for Ba Bei Hui Ja (BBHJ) – National Registry in China for Birth Family Search. They will come to your hotel for a 5 minute process if you desire. Visit your former orphanage? If the orphanage no longer exists, visit the city where it was located? Other: What has your experience been growing up as a Chinese Adoptee? With your adoptive family?What is your understanding about how you came into care? How (if at all) has this changed over time? Δ