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| TRIP NAME/NUMBER: | | TRIP DATE: | ___ / ___ / 2007 |
| PERSONAL INFORMATION |
| FULL NAME: | | OCCUPATION: | |
| HOME PHONE: | WORK PHONE: | FAX: | EMAIL: | |
| include area code | include area code | include area code | enter valid email address |
PASSPORT#:
Please fax us a photocopy of Passport details page (we may need these details to implement Medivac procedures) | enter passport number |
| EMERGENCY CONTACT: | | PHONE: | |
FOOD PREFERENCES/DISLIKES:
TEE SHIRT SIZE : SML MED LGE XL
EXPERIENCE AND TRAINING:
PREVIOUS CLIMBING EXPERIENCE:
PREVIOUS TREKKING EXPERIENCE:
GENERAL PHYSICAL CONDITION: AGE: APPROX WEIGHT/HEIGHT:
PHYSICAL TRAINING FOR THIS TRIP
MEDICAL INFORMATION (this is very important)
MEDICAL HISTORY (things we should be aware of i.e. allergies, heart problems, diabetes, mental disorders):
MEDICATIONS:
MEDICAL INSURANCE COMPANY: POLICY#:
(Must cover Medivac) TELEPHONE & CONTACT NAME:
Credit Card No: Expiry Date:
Visa, Master Card, Amex, Other
We highly recommend a pre-trip physical; let your doctor know you will be doing strenuous exercise possibly at high altitude and that you are traveling to Papua New Guinea.
| AIRLINE INFORMATION PLEASE FAX OR SEND A COPY OF YOUR ITINERARY:
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| ARRIVAL AIRLINE: | FROM: | FLIGHT#: | DATE:
__ /___ / 2007 | TIME:
______ AM/PM |
| | | | | |
| DEPARTURE AIRLINE: | FROM: | FLIGHT#: | DATE:
__ /___ / 2007 | TIME:
______ AM/PM |
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HAVE YOU SENT A DEPOSIT OR FINAL PAYMENT, READ ALL POLICIES, EQUIPMENT LISTS AND PRE-DEPARTURE INFORMATION?
PLEASE FILL OUT IN FULL AND RETURN WITH LIABILITY RELEASE PNG TREKKING ADVENTURES, PO BOX 91 GORDONS, PAPUA NEW GUINEA
CONTACT DETAILS: (675) 325 1284 (675) 686 6171 Fax (675) 323 0984,
Email: info@pngtrekkingadventures.com
Download this page as MS WORD document or ADOBE PDF file.
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