Flora and Fauna Field Tours
RESERVATION & PERSONAL INFORMATION FORM
Please complete this form and mail with your applicable deposit made payable to:
WORLDWIDE QUEST INTERNATIONAL INC.
The full completion of this form is MANDATORY for each trip – 1 form per person
TRIP NAME: __________________________________________TRIP DATE: __________________________
Last Name: ___________________________________ First Name(s): _________________________________
(Please show name exactly as it appears in your PASSPORT
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Male qFemale Title: ______________Street Address: ___________________________________________________City/Town: ___________________
Province/State: _____________________ Postal/Zip Code: ________________ Country: ____________________
Telephone: Home (____)_____________________________ Work (____)_______________________________
E-mail Address: ______________________________________________________________________________
Fax: (____)_____________________________________ Date of Birth: (mm/dd/yy)________________________
Occupation (if retired, please enter past profession): __________________________________________________
MEDICAL INFORMATION:
If you have any of the following medical conditions, currently or a history, please check them off:
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diabetes q heart condition q cancer q asthma q joint ailments qwalk with caneq
phobias q allergies _________ q memory loss q recent surgery quses hearing aidIf you have any other physical or emotional limitations that would impact your ability to participate fully in this trip, please list them: _______________________________________________________________________________
Are you on any medications? Please list: ___________________________________________________________
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smoker q non-smokerSPECIAL DIETARY REQUIREMENTS:
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vegetarian q diabetic q low-fat & -sodium q gluten-free Other: ______________________INTERESTS:
Birds
q Botanyq Mammalsq Marine Lifeq Geologyq Culture/Historyq Photographyq ArtqOther: _______________________________________________________________________________
In case of Emergency, please contact: (Please tell your contacts that you have given us their names)
1. Name: Relationship: Tel: W (___)____________H (____)____________or
2. Name: Relationship: Tel: W (___)____________H (____)______________
PLEASE FILL OUT BOTH SIDES OF PAGE►►►►
DEPOSIT: $_____________
qCheque, Money Order, Bank Draft qMasterCard qVisaCredit Card Number: _________________________________________ Expiry Date: ____________________
Cardholder Name (as it appears on the card): ________________________________________________________
Cardholder Signature: __________________________________________ Date: __________________________
BALANCE PAYMENT: (due ninety days before the tour begins)
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I will send the balance payment by cheque / money order / bank draft.q
I will pay my balance payment using the credit card listed above.q
I will pay for my airline ticket using the credit card listed above.(after a discussion with an agent about schedule and price)
SINGLE TRAVELLERS:
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I am travelling alone and am willing to share (Worldwide Quest will try to find a roommate for me).Note: If Worldwide Quest cannot find a roommate for you, the single supplement will apply.
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I would like to have a guaranteed single room and will pay the single supplement.AIR INFORMATION:
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I DO require assistance with my air arrangements.q
I DO NOT require assistance with my air arrangements.(Once the trip has been confirmed as operating you may arrange your own air, but we must have a copy of your itinerary.)
Departure City or Airport: _______________________________________________________________
Seat Preference: _______________________ Meal Request: ___________________________________
Frequent Flyer Number(s): ______________________________________________________________
PASSPORT INFORMATION:
**NOTE: we will not be able to send your Final Documents until we have received this information
Passport #: .............................................................. Nationality: …..............................................………..
Issued At: ............................................................... Issue Date (mm/dd/yy):................................………..
Place of Birth:…………………………………….. Expiry Date (mm/dd/yy):……………………………
Your passport should be valid for at least 6 months beyond the expected date of your return home.
In completing this form, I affirm that I am in general good health, capable of performing the required exercise to participate, and that I have not recently been treated for, nor am I aware of, any condition that would jeopardize myself or other members of this tour. I accept as my personal risk the hazards of such participation, and will not hold Worldwide Quest International Inc. or its representatives responsible. I confirm that I am over the age of 18 and hereby release and forever discharge Worldwide Quest International Inc., its officers, directors, servants and agents from any liability whatsoever arising as a result of my participation in this trip, and I declare this release is binding upon me, my heirs, executors and assigns. I agree that this agreement shall be governed in all aspects by, and interpreted in accordance with, the law of Ontario, Canada.
I have read the Detailed Trip Itinerary as well as the Terms & Conditions outlined in the current Flora and Fauna or Quest Nature Tours brochure/website. I also understand that the unique nature of this type of travel involves accommodations, transport, safety and medical facilities not found on a conventional vacation.
SIGNATURE:
__________________________________________ DATE: ___________________________