2018 Road Trips 1 General Information2 Name(s) of Attendees3 Trip Pricing Information4 Payment Information 2018 Road Trip Information Welcome to the 2018 Lehigh Valley Phantoms Phan Club Road Trip Signup page! This year we have Three big road trips planned! If you plan on attending more than one of the road trips this year, you will need to fill out the form for each trip here, sorry, but this had to be done in order to keep the data separate and allow you to have a different number of people attending each trip. Please fill out this form for the selected trip(s) you are currently signing up for. Which Trip are you signing up for?*Please select the trip you are signing up for. Note: All trips must have payment in FULL no later than 30 days prior to the date of the trip.Select OneBelleville/Toronto - December 1st & 2ndProvidence/Hartford/Springfield - January 4th, 5th & 6thCharlotte - February 22nd & 23rdAre you putting a Deposit down or payment in full?*A Deposit of $50 Per Person is required to secure your spot(s) on the bus. However, you can chose to pay for the trip in full.Select OneDepositPayment in FullSingle or Double Occupancy Room?*Select OneSingle OccupancyDouble Occupancy (Max of 4 in a room)Passport Required*The trip to Bellville/Toronto is leaving the United States and because of this, a Valid Passport is required for each person going on the bus trip. Please, place a checkmark on this section to acknowledge that you are aware and will ensure that a valid passport is required for ALL persons you are signing up for this trip. Yes, I acknowledge that I am aware that a valid Passport is required for the Bellville/Toronto Trip. Number in your group?*How many people are you paying for (or making a deposit) on, please include yourself in the count of the number of people.Please enter a value greater than or equal to 1.All are current members of the Phan Club*This trip is for members of the Phan Club, if any person in your group is NOT a member of the phan club, a $15 Per Person charge will be added to your reservation.Select OneYes, all going are current membersNo, we have people are are not members.Number of Non-Members*Please let us know how many in your group are non-members of the Phan Club. A $15 Surcharge will be added for each non-member signing up for trip (they will become a member for future road trips)Please enter a value greater than or equal to 1. Attendees Llist*Please provide us with the Name and email address of attendees (the email address is being provided so we can keep everyone informed of trip details). Please click the '+' on the right to add additional names.First NameLast NameEmail Address Deposit for Bus Trip to Belleville/Toronto Price: $0.00 Deposit for Bus Trip to Providence/Hartford/Springfield Price: $0.00 Deposit for Bus Trip to Charlotte Price: $0.00 Cost for Bus Trip to Belleville/Toronto Price: $0.00 Cost for Bus Trip to Providence/Hartford/Springfield Price: $0.00 Cost for Bus Trip to Charlotte Price: $0.00 Non-Member Surcharge Price: $0.00 Name* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Paying By:*Select OneCredit CardPayPalPayPal Payment Since you have selected payment via PayPal, we wanted to inform you that you will be redirected to the PayPal page when you select 'Confirm Registration' button below. You are not fully registered for this trip until your payment has been made via PayPalCredit Card Payment Since you have selected payment via a credit card, we wanted to inform you that your card will be charged when you select 'Confirm Registration' button below. You are not fully registered for this trip until the payment has been accepted by credit card company.Credit Card* American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Security Code Cardholder Name Total $0.00 EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.