Alaska 2015 info form

June 20145 Alaska Trip: Personal info and emergency form

* Indicates required field

Name: First, Middle, Last *

Nationality *

Gender *

Date of birth *

Height *

Weight *

In case of emergency, please contact (specify relationship): *

Emergency contact’s telephone number: *

If you have any medical conditions that we should know about, or medications you regularly take, please discuss these: *

Do you have any food allergies or special diets? (e.g. vegetarian, lactose-intolerant, gluten-intolerant/gluten-free, etc). Please describe: *

What do you especially like (or not like) to eat? This information is very useful to us in planning and serving meals. Please be specific. *

Briefly describe your health, fitness, and activity levels: *

Briefly describe your previous outdoor experience: *

What aspects of the tour / what activities are you most looking forward to? *

OPTIONAL GEAR RENTAL: We provide tents and all other necessary camping gear, except sleeping bags and sleeping pads . If you would like to rent these, please let us know. Sleeping Bag/s ($25/bag). Sleeping Pad/s ($10/pad, non-inflating)

Choose option *

Sleeping bag Sleeping pad Sleeping bag + pad No rentals, I’m bringing my own

TRAVEL INSURANCE: Travel insurance, including coverage for health, accident, emergency evacuation, accidental death, baggage loss, and trip cancellation, is strongly recommended for all trip participants. If you cancel or miss your tour for any covered reason (injury, illness, etc), trip cancellation insurance should reimburse you. Inexpensive policies of this sort are routinely issued by most travel and insurance agencies, or you can contact a travel insurance company such as Travel Guard, tel. 800-826-1300, www.travel-guard.com

Health / Travel Insurance Provider/Carrier *

Health Insurance Policy Number *

Health Insurance Provider/Carrier Telephone Number *

Are you shabbat observant? *

Submit