Jul 19 Costa Rica contact form

Summer 2019 Costa Rica Trip: Personal info and emergency contact form

* Indicates required field

Name *

First

Last

Arrival day in Costa Rica *

Arrival airline + flight number *

Arrival time *

Departure airline + flight number on Sunday, Aug 4 (if applicable) *

Departure time *

Dietary restrictions *

Are you shabbat observant? *

Health Insurance Policy Number *

Health Insurance Provider/Carrier *

Health Insurance Provider/Carrier Telephone Number *

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

Emergency contact’s telephone number: *

Any Medications you are taking, including dosage: *

Do you have any allergies? If so, specify: *

On a scale of 1-10, with 10, being very active, how would you rate your physical activity level? *

On a scale of 1-10, with 10, being very experienced, how would you rate your experience with:

Walking/Hiking *

Cycling *

Swimming *

Snorkeling *

Whitewater rafting *

Submit

costa_rica_experience_august_2016.pdf
File Size:	4087 kb
File Type:	pdf

​Summer 2019 Costa Rica Trip:​Personal info and emergency contact form