GENERAL CONTACT AND HEALTH FORM

GENERAL HEALTH & CONTACT INFORMATION FORM
To our adventurers,

Chile Nativo offers excursions that range from easygoing photo safaris to vigorous hikes that last a full day. Regardless of the degree of difficulty, we are committed to your safety.

Our guides are trained in first aid and carry radios for quick communication. They are also thoroughly familiar with the physical conditions required for each excursion and any dangers that could present themselves from changing climatic conditions.

We like to be prepared. Please help our guides to provide you with safe, enjoyable journeys by letting us know a little about you. The information you provide may not necessarily prevent you from partaking in excursions and all information you supply will be kept in strict confidentiality.
REGISTRATION & CONTACT INFO
Name*

NAMELAST NAME
Trip Name*
Ex: John x 2 (WNAT) (23 Jan 22)
Departure Date*

DAYMONTHYEAR
Email*
Example@Example.com
Address*

CITYSTATE

ZIP CODECOUNTRY
Passport Number*
Issuing Country*
Exp date*
Phone Number*

COUNTRY CODEAREA CODEPHONE NUMBER
Relationship with other travelers in the group
HEALTH & EMERGENCY INFORMATION
Date of Birth*

DAYMONTHYEAR
Age*
Gender*
Blood Type
Emergency Contact*
Relationship with Contact*
Contact Phone Number *

COUNTRY CODEAREA CODEPHONE NUMBER
Are you travelling with any insurance*

YesNo
International Insurance Company *
Company Contact Phone Number*

COUNTRY CODEAREA CODEPHONE NUMBER
Policy Number*
* If you do not have health or travel insurance when completing this form: I agree to assume full responsibility for any medical expenses, evacuation, repatriation or any travel related costs before, during or after my trip. Please let us know if you have coverage before your trip departure.

I agree
MEDICAL INFORMATION
Any medical information that we should be aware of (i.e. diabetes, heart problems, high blood pressure, epilepsy, asthma etc)?*

YesNo
Please Explain*
Have you been hospitalized within the past six months?*

YesNo
If yes, what were the circumstances?*
Are you currently taking medication that could impair your physical ability or awareness?*

YesNo
List the medications*
Any allergies*

YesNo
Do you have allergies to certain foods*

YesNo
Please give us details*
Do you have special food requirements (Vegetarian, Vegan, Gluten Free, Celiac, etc.)*

YesNo
Please explain your preferences or food restrictions*
Special tour information
Select the activities of your trip with us, you can choose more than one option:*

KayakHorseback ridingWhale WatcchingTrekkingEBike
Height*
Weight*
Click to edit

Meters / kilogramsFeet - Inch / Pounds
Kayaking Expierence*
Clothing size*
Shoes size*
Horseback Riding Expierence*
Accomodations in Puerto Natales*
Accomodations address
Bike Expierence*
Are there children in the group?

YesNo
How old are the children?
I have read and completed this form with real and reliable information about my personal information and health.*

I AGREE
Name*

NAMELAST NAME
DATE*

DAYMONTHYEAR
Thank you for filling out this form for us, it will allow us to give you a better service.
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GENERAL HEALTH & CONTACT INFORMATION FORM

REGISTRATION & CONTACT INFO

HEALTH & EMERGENCY INFORMATION

MEDICAL INFORMATION

Special tour information