Participant Information Form. *Please fill in this information as completely as possible Name First Name Last Name Email * Phone (###) ### #### What trip (or trips) are you signed up for? Trip Starting Date: MM DD YYYY Trip Ending Date: MM DD YYYY Your flight arrival information (flight dates, flight numbers, arrival/departure times: Passport number, nationality and expiration date: * Emergency contact: Accommodation: Are you booked as a single or sharing a room with someone? If sharing, with whom? Do you have any special dietary requirements or other special requests? Do you have any physical limitations or medical conditions we should be aware of, medications you are taking, etc? Please give a brief description of your outdoor/travel and photography experience: Responsibility Statement: By submitting this form I hereby certify to Patagoniaphoto.com that I take full responsibility for any personal medical, physical or psychological conditions that may arise during my travels with Patagoniaphoto.com. I am unaware of any medical, physical or psychological issues that could in any way impair my ability to make this trip and I take full responsibility for the provision of any emergency medical care I may need during the tour and for having personal medical and travel insurance to cover myself in case of an emergency. If there are any changes in my medical or physical condition before or during the trip, I will immediately bring it to the attention of the Patagoniaphoto.com staff. * Agree Thank you!
