Name*Enter your full name as it appears in your passport (Cuba does NOT stamp passports) First Middle Last Date of Birth* YYYY slash MM slash DD Gender* Male Female Address* Street Address Address Line 2 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 Telephone* Email* If choosing DOUBLE occupancy:Name of relative or friend you are sharing the room with Cost Breakdown (taxes included): Check appropriate package* Participant Land Package, SINGLE occupancy: $2085 USD Participant Land Package, DOUBLE occupancy: $1980 USD NON-Participant Land Package, DOUBLE occupancy: $1725 USD Cost Price: $ 0.00 Total $ 0.00 University credits are available when attending the KoSA Cuba study program. Please contact us for cost. YES, I want University Credits Price includes: Hotel room at the Four-Star Palco Hotel - 7 nights. Transportation during the entire week for all group activity. Transportation to & from airport not included. 2 meals per day (drinks NOT included), all conferences, classes and festival activities in Havana and accreditation for the Havana Rhythm and Dance Festival - la Fiesta del Tambor full Access Pass. KoSA full time translator, coordinator and in house assistance during duration of the program. All instruments provided Prices do not include: Drinks Flight to Cuba. Major area of interest: Bongos Timbales Congas Drumset What is your level of experience: Elementary (one or two years of study) Intermediate (junior high school or early high school) Advanced (high school, early college) Professional (late college, professional player) NOTE: March 4th & March 11th are travel days. Program begins Monday 10AM & ends with Saturday night concert.General Conditions: A non-refundable deposit of $700 is required at the time of booking. The full payment is due by February 2nd 2018 and is also non-refundable. We suggest you book early to guarantee plane seats. Airline seats are limited. It is your responsibility to have a valid passport to travel to Cuba. All participants must have active health and medical coverage during your stay in Cuba. Payment Method* Credit Card Cheque Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name CurrencyUSDIf paying by check, please mail to: KoSA Communications International PO Box 333, Station St. Jacques Montreal, QC H3C 2S1 CanadaCAPTCHA Formulaire d'inscription français Formulario de Inscripción en Español If paying by check, please mail to: KoSA Communications International PO Box 333, Station St. Jacques Montreal, QC H3C 2S1 Canada For more information: 514-482-5554 Toll Free: 1-800-541-8401 info@kosamusic.com