Trip Application & Reservation Request form

or click here for PDF version

Please print this form and email to:

Explore Bolivia, Inc.
2510 North 47th St.,
Suite 207
Boulder, CO 80301-2337

I would like to register for the following adventure trips(s):
1. _______________________________________ Dates: __________
2. _______________________________________ Dates: __________
Enclosed is a deposit for: _____ person(s) at U.S. $300.00 per person, per adventure trip for a total of: $ _______.

I agree to pay the balance due no later than 60 days before the departure date of the adventure trip applied for on this application form. I understand the application(s)/reservation(s) and deposit(s) accepted by EXPLORE BOLIVIA are subject to the Terms and Conditions regulations, the Medical and Limited Liability Release Agreements, and the Participant(s) Responsibility Code if signed by each member of an adventure trip and accompanied by the required deposit.

Applicant's name: __________________________________________________ (as it appears on passport)	Age: __________ Height: ________
Address: _____________________________________________________	Weight: ________
City: ________________ State: ____ Postal/ZIP Code: ________	Sex: _____
Country: _____________________________	Do you have a valid passport? _____
Occupation: ___________________________________________	Passport #: _________________
Home Phone: _____________[day/eve] Work Phone: ____________ [day/eve]	Expiration Date: ______
Date of Birth: __________ Country of Citizenship: _______________	Are you physically active? ______
Are you a vegetarian? _________	Do you smoke? ______
Do you have any dietary restrictions, or are there any foods that you do not eat? _____ If yes, what are they?___________________________________________
Emergency Contact Person: (Name, Address & Phone or Fax Number & relationship) ______________________________________________________________________________________________ _______________________________________________________________________________________________

** For your safety, and so that we may prepare accordingly, please tell us of any medical conditions you have (or may have had) that may affect your participation or safety while on a trip with EXPLORE BOLIVIA. This information will be held in strict confidence. It helps us and you prepare for the trip. Please check with your personal doctor as to your medical needs and or medications (if any) that you might need to bring with you.

______________________________________________________________________________________

Are you allergic to any medicines, antibiotics, foods, insect stings or iodine?
______________________________________________________________________________________

Accommodations:
Are you willing to share a room and/or tent with someone? ______________________.
Would you like us to assign you a room/tent mate ? (Y/N) _______.
If you prefer single accommodations, are you willing to pay the current single supplement fee? (Y/N) _______.

Signed: ___________________________________ Date: ________

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