ADVENTURE INTERNATIONAL

BOOKING FORM

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	YES NO