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Please Note: If you do not receive a confirmation email within three business days of submitting this form please call Live Aboard Coordinator at (361) 888-4873 ext.321 or 800-LADY LEX ext.321. Thank you.
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Group Information
Group Name
*
Contact Person
*
First
Last
Contact Person Title
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Enter Email
Confirm Email
Day Time Phone
*
Evening Phone
*
Group Details
Date Request
*
Date 2nd Choice
*
Group Age Range
*
5-7
7-9
9-12
12-15
15-18
18+
Number of Male Children
*
Number of Female Children
*
Number of Male Adults
*
Number of Female Adults
*
Does any group member have a special dietary requirement?
*
Yes
No
Are there any medical conditions of which LEXINGTON should be aware of?
*
Yes
No
If yes, please explain:
*
If yes, please explain:
*
* Please notify us if anyone in your group has needs or limitations requiring special attention (language, etc…)
Group's First Visit?
*
Yes
No
If No, what was your group's last visit date?
*
Which Program would you like to set up
*
One Night
Two Night
Estimated Time of Arrival
*
:
HH
MM
AM
PM
Special Instructions/Remarks:
How did you hear about Live Aboard?
PAYMENT
Payment Amount
*
Pay deposit at this time? ($100 per day)
Pay total amount at this time? ($55 per person)
Deposit Charge
Total Charge
Type of payment:
*
Please select
Credit card number below
Call me for credit card number
I will call with credit card number
Credit Card Type
*
Please select
AMEX
Discover
Master Card
Visa
Name as it appears on card
*
First
Last
Card Number
*
Expiration Month
*
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January
February
March
April
May
June
July
August
September
October
November
December
Expiration Year
*
----
2018
2019
2020
2021
2022
2023
2024
2025
CVV2 (3-digit number on the back of card)
*
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