Registration form – Paraty Explorer – Adventure & Active Travel in Brazil

Client info form – Please complete and submit

* Indicates required field

Name *

First

Last

Email *

Passport number *

Nationality *

Trip dates *

Date of birth *

Sex *

Height *

Weight *

Are you under the care of a physician? *

If so, what is the condition being treated? *

Have you had a serious illness, injury or operation? *

If so, what was the nature of the illness, injury or operation and date? *

Have you been hospitalized or had a serious illness within the past five years? *

If so, what was the nature of the illness and date? *

What medication are you taking (if any): *

Other health issues (if any): *

Evaluate your health: *

Can you swim? *

Evaluate your swimming ability: *

Do you eat seafood? *

List any special dietary requirements or food allergies *

Travel Medical Insurance info (provider, policy no., contact info) *

Next of kin: (Name, Email, Contact telephone) *

If other please specify: *