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Home > Adventures > Reservation Form
Traveler Information
First Name
Last Name
Date of Birth
dy
day month year
Height ft in
Weight lbs
Gender
Male
Female
Home Phone
Work Phone
Cell Phone
Email Address
Street Address
Country
City
State
Zip / Post Code
Passport Information
Full name on passport
(exactly as it appears)
Passport Number
Issue Date
dy
day month year
Expiry date
dy
day month year
Place of Issue
Place of Birth
Citizenship
Please note passports must be valid for 6 months after the last day of your trip. If you need to renew your passport, please send us the updated details upon receipt. Note: Some countries require 2 consecutive blank pages.
Health & Emergency Information
I would rate my health as:
Excellent
Good
Fair
Poor
List any health-related facts or special needs that you think we should be aware of
List any dietary restrictions or preferences
Person to contact in case of emergency
Home Phone
Work Phone
Email
Accommodations
What type of bedding do you prefer?
One double / king
Two twin beds
Triple
Quad Family
Smoking
Who are you sharing a room with?
Celebrations
While traveling, will you be celebrating a birthday? Date
dy
day month year
Will you be celebrating an anniversary? Date
dy
day month year
Insurance Waiver
I have been offered Travel Protection insurance
I DO intend to obtain travel insurance
I DO NOT intend to obtain travel insurance
We recommend these companies
Travelex Insurance from Africa Adventure Consultants
Travel Guard from Africa Adventure Consultants
Donations
Africa Adventure Consultants donates $25 to a worthy cause for every client who travels with us.
Please choose
Mwangaza An Illinois not-for-profit corporation that supports health-related projects focusing on the physically disabled in Africa and developing world. In Swahili, mwangaza means beacon.
AfricAid a non-profit organization that supports girls' education in Africa in order to provide young women with the opportunity to transform their own lives and the futures of their communities.
International Flight Information
If you made your own air travel arrangements, please attach a copy of your itinerary or email it separately.
Additional Information
I have read and agree to Africa Adventure Consultants' Indemnity Agreement
I have read and agree to the Terms and Conditions
Please sign me up for the Africa Adventures newsletter
Acknowledgement
By checking this box and filling in my name in the signature box, I acknowledge that I am creating an electronic signature that has the same legal force and effect as a handwritten signature and that indicates that I have, on the submittal date, read and understood the indemnity, and terms and conditions stated above for my travel package and I acknowledge that these terms and conditions affect my legal rights and agree to be bound by their terms. My signature also signifies my intention to relieve and indemnify Africa Adventure Consultants, Inc., D/B/A "Africa Adventure Consultants, Inc.", its owners, officers, directors, employees, affiliates, agents, contractors and subcontractors from any liability for personal injury, property damage or wrongful death which I might suffer during my participation in the scheduled trip.
Signature Box (Enter your full name):
Date: