All key data must be filled out and sent before the trip starts. Some information is not mandatory but we request that each and every guest fills out the form as fully as possible to help us ensure you have a successful and safe trip.

 

 

GUEST INFORMATION

Trip Name / Start Date
First Name
Last Name
Date of Birth
Email Address
Telephone / Mobile
Weight
Passport Number
Address
City / Town
State / County
Country
Postal Code
If sharing room please indicate with who

 

 

EMERGENCY CONTACT

First Name
Last Name
Relationship
Day time telephone
Evening telephone
Mobile
Email Address


Comprehensive insurance should be purchased before traveling to Africa. Travel Insurance should at least cover personal accident, medical expenses, hospitalization, repatriation, trip curtailment, cancellation, and loss of valuables


INSURANCE INFORMATION

Insurance Company
Insurance Reference
Insurance Emergency Telephone
Any other relevant information

 

 

MEDICAL & DIETARY INFORMATION

Allergy 1
Alergic reaction 1
Medication required 1
Allergy 2
Alergic reaction 2
Medication required 2
Allergy 3
Alergic reaction 3
Medication required 3
Any other allergies or medication

 

 

MEDICATION

Medication 1
Medication 1 is taken for
Medication 1 dosage
Medication 1 start date
Medication 1 known side effects
Medication 2
Medication 2 is taken for
Medication 2 dosage
Medication 2 start date
Medication 2 known side effects
Medication 3
Medication 3 is taken for
Medication 3 dosage
Medication 3 start date
Medication 3 known side effects
Other medication info
MEDICAL HISTORY YES NO
I have had a seizure within the last 2 years YES NO
Hospitalization / Emergency room visit in the past 2 years YES NO
History of heart attack, bypass, or rhythm abnormality YES NO
Medical device (hearing aid/prosthetic device) YES NO
Orthopedic problem, neck, back, ankle or knee YES NO
Currently pregnant YES NO
Asthma YES NO
Diabetic requiring medication YES NO
Organs removed YES NO
If yes, which one(s)
HEART RISK ASSESSMENT YES NO
Diagnosed high blood pressure YES NO
Smoker YES NO
Abnormally high cholesterol level YES NO
Family history of heart attack, bypass, sudden unexplained death before 60 YES NO
Unexplained chest pain, shortness of breath, heart palpitations, sweats YES NO
Fainting spells, dizziness YES NO


Any of our trips involving hiking, mountain biking or other strenuous activity requires that participants be reasonably fit. Please indicate below regularly performed exercise activities. For safari only trips it is not necessary to fill out this section

 

 

ACTIVITY LOG

Activity Frequency / time / distance

 

 

ARRIVAL AND DEPARTURE DETAILS

Date of arrival
Port / Airport of arrival
Airline and number
Time of arrival
Date of departure
Port / Airport of departure
Airline and number
Time of departure


Wherever possible we will always try to cater for specific preferences or interest such as bird watching, animal behavior or cultural interests. Please let us know any additional information below

 

 

PREFERENCES & SPECIAL INTERESTS

Drinks preferences
Other preferences
Additional information


I have read and fully understand Adventure International, LLC Terms and Conditions
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