Personal Info
|
(*)Package Type
|
(*)Departure Date
|
(*)First & Middle Name:
|
(*)Last Name
|
Birth date: (MM-DD-YYYY)
|
Sex
|
Nationality
|
Civil Status
|
(*)E-mail
|
Phone
|
(*)City/State
|
(*)Country
|
(*)Address
|
Zip Code
|
Passport Number
|
Expiration Date
|
Issue Date
|
Profession
|
Job position / Title
|
Company
|
| |
|
|
(*)Which one of these activities defines you best? (you can choose up to five alternatives)
Whale Watching
Bird Watching
Nature Photography
Trekking
Kayaking
Rafting
Jetboating
Horseback riding
On board lectures
|
| |
|
(*)Health
(all these fields are required)
|
| Your approximate weight: |
Kg
or
Lb |
| Your approximate height: |
Cm
or
In |
| Are you physically active? |
|
| Do you smoke?
yes
no |
(*)Health / Special (all these fields are required)
|
| Do you suffer from any medical condition?
yes
no |
| if so, specify:
|
| Are you in any way handicapped?
yes
no |
| if so, specify:
|
| Do you take any necessary special medication?
yes
no |
| if so, specify:
|
| Do you suffer from allergies regarding food or environment?
yes
no |
| if so, specify:
|
(*) Food and Beverage (all these fields are required)
|
| Do you drink alcohol?
yes
no |
| Do you have food restrictions that require special attention?
yes
no |
if so, specify:
|
Flight information
|
Arrive to SCL
|
Flight
|
Time
|
Arrive to PMC
|
Flight
|
Time
|
Depart from PMC
|
Flight
|
Time
|
Depart from SCL
|
Flight
|
Time
|
| Coments
|
