Booking form and health statement

Mr./Mrs.*< name*
Gender*

FemaleMaleOther
Address*
City/Town*
Country*
Telephone

Area CodePhone Number
Passport number*
Issued

MonthDayYear
Date
Valid until

MonthDayYear
Date
E mail address*
example@example.com
Date + place of birth*

MonthDayYear
Date
Special diet wishes*
Emergency contact, names and tel.

Area CodePhone Number
I declare to have a health insurance that covers the booked voyage*

YesNo
I declare to have travel insurance that covers the booked voyage*

YesNo
Trip number and name of the tour*
Date of departure

MonthDayYear
Date
Cost of the journey per person
Cabin preference

Shared cabin with private shower and toilet (+150 Eur / journey)Shared cabin without private shower and toiletSingle supplement for one person in a private cabin (+70% / journey)
I would like to rent bed linens at 15 Eur per journey

YesNo
I allow Tilvera Expeditions to print my/our tel. number on the passenger list, so that other passengers on this trip can contact me/us for a collective trip to the port of departure. (Please mark if you agree * delete as appropriate

I we, the undersigned declare to be familiar with the travel conditions of Tilvera Expeditions, to be found on our website: General Passenger Terms which apply to this contract. The undersigned is also responsible for the obligations of the fellow-travellers, mentioned in this form under this agreement.
Date

MonthDayYear
Date
Signature

Clear
Health Statement
Tilvera Expeditions makes every effort to ensure the safety of every person on board. Our guests are expected as well to assume responsibility for their own safety. Insufficient mental or physical health may create undue risks not only to yourself, but it is essential to realize that illness or accidents may also threaten the safety of other guests and crew and may seriously disrupt the sailing program of the vessel. If you are in doubt about your fitness for a sea voyage on a sailing and rolling ship you are requested to seek your doctor's advice first. To prevent misunderstandings please fill in and sign this document

months? YesNo Do you use anticoagulants (bloodthinners)?YesNo Do you suffer from other medical conditions of which Tilvera Expeditions must be informed? If so,

please make note of medication

List of my medication including dosage:
Do you need help in climbing stairs or taking thresholds of 60 cm. ft)?

YesNo
Are you by experience very prone to motion sickness (sea sickness)?

YesNo
Do you have diabetes? If yes, do you need injections?

YesNo
Do you have any respiratory problems? (e.g. asthma)

YesNo
Do you have heart or circulatory problems?

YesNo
Do you have epilepsy?

YesNo
Do you have an increased risk for infections or did you have radio- or chemotherapy in the past 24

YesNo
Name
Signature

Clear
Place
Date

MonthDayYear
Date
By signing this Health Statement I declare to have answered these questions truthfully and that I am aware that I will participate in a voyage on the Tilvera at my own risk
I would like to subscribe to Tilvera newsletter to receive news and updates about Tilvera project and coming adventures:*

YesNo
Should be Empty:

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Health Statement