The CML Life Africa Leadership Summit - hosted by The Max Foundation

Please enter your information below to register for the conference.

Full Legal Name

Please enter First and Middle names in the "First Name" box and Surname in "Last Name" box.

First Name

Last Name

Gender

Email Address

Phone (Please include country code)

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Which airport works best for your outbound and return flights to/from Entebbe?

Name Exactly as Listed on Passport

Passport Number

Passport Expiration Date

Any regular medications, allergies, or other special needs?

If yes, please explain

In Case of Emergency, Please Notify:

Relationship to Emergency Contact

Emergency Contact Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Phone

Emergency Contact Email

Primary Physician Name

Primary Physician Office Phone

Primary Physician Office Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please sign me up for Andrew W Lyon Travel email updates

By entering your name below and submitting this form, you agree that all information on this application is true