Another Way Medical/Liability Form

Another Way Medical/Liability Form
Please Complete and Submit at Least 10 Days Prior to Trip
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Passport Number: blanks Expiration Date: blank
Emergency Contact

First NameLast Name
Date of Birth

MonthDayYear
Date
Height: blanks Weight: blank
Emergency Contact Phone
Please enter a valid phone number.
List Any Allergies
List Any Regular Medications Taken
List Any On-going Or Recurring Medical Conditions
List Any Dietary Restrictions
List Any Vaccinations
Any Other Relevant Information
Liability Release and Assumption of Risk Agreement

Please read the Terms and Conditions below before signing. All travelers must sign and complete this form. A separate form must be completed for each traveler.

Travel Insurance Option:

Your upcoming trip is a significant investment, which involves risks. Another Way and Routes to Africa, LLC recommend that clients purchase a comprehensive travel insurance plan valid for the entire duration of their trip. This insurance should cover you for events such as trip cancellation, delay or interruption, lost or delayed baggage, emergency accident, illness and evacuation, 24-hour medical assistance, traveler’s assistance, and emergency cash transfer. We suggest you find a suitable insurance company relevant to your situation. The total premium should be based on each traveler’s age and total per person trip price, including airfares.

Comprehensive travel insurance has been explained and recommended to me relative to my forthcoming trip.
I have read and understand the choice for travel insurance.

Yes, I have purchased Travel InsuranceNo, I understand and have chosen to not purchase Travel Insurance
Agreement:

I understand trip requirements and responsibilities, and I agree to terms.

I have received necessary vaccinations and will take prescribed malaria medication.

I, the undersigned, will not hold Another Way, Routes to Africa, LLC, or its directors responsible for any injury, loss, trip disruption, or for any expense incurred due to medical needs, extra transport, acts of God, airline changes, lost luggage, or failure on the part of outside vendors (I.e. accommodations, vehicle rentals).
Signature

Clear
Should be Empty:

Another Way Medical/Liability Form

Please Complete and Submit at Least 10 Days Prior to Trip