Park Trek Booking Request

Your Email	*
Tour Name
Departure Date
Payment via	Cheque Money Order Credit Card Cash
Title	Mr Mrs Ms Miss
Firstname
Lastname
Street Name
Address (cont)
State
Province Zip/Postal Code
Country
Telephone (BH)
Telephone (AH)
Fax
Age Range	Under 20 20 - 40 40 - 50 50 - 60 60 plus
Sharing Tent	I/we will share a tent
Preferred Companion (if known)
Dietary Requirements	I have no special dietary requirements I DO have special dietary requirements
	If yes please explain dietary requirements
Have you had any medical	Yes No
treatment in the last year	If so, please give details
Do you suffer from asthma	Yes No
Do you suffer from diabetes	Yes No
Do you suffer from heart disease	Yes No
Do you have travel insurance	Yes No
	Please provide travel insurance details
Health Insurance	Yes No
	Please supply health insurance number (if applicable)
Ambulance Subscription	Yes No
	Please provide subscription number (if applicable)
In case of emergency	Please provide next of kin details: name, phone no. etc

We are not making an assessment or otherwise of your physical condition. You are making your booking with this understanding. Please read our booking conditions.