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
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.
MEDICAL INFORMATION
Any medical information that we should be aware of (i.e. diabetes, heart problems, high blood pressure, epilepsy, asthma etc)?
Please Explain
Have you been hospitalized within the past six months?
If yes, what were the circumstances?
Are you currently taking medication that could impair your physical ability or awareness?
List the medications
Any allergies
Do you have allergies to certain foods
Please give us details
Do you have special food requirements (Vegetarian, Vegan, Gluten Free, Celiac, etc.)
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:
Height
Weight
Click to edit
Kayaking Expierence
Clothing size
Shoes size
Horseback Riding Expierence
Accomodations in Puerto Natales
Accomodations address
Bike Expierence
Are there children in the group?
How old are the children?
I have read and completed this form with real and reliable information about my personal information and health.
Name

NAMELAST NAME
DATE

DAYMONTHYEAR
Thank you for filling out this form for us, it will allow us to give you a better service.
Should be Empty:

GENERAL HEALTH & CONTACT INFORMATION FORM

REGISTRATION & CONTACT INFO

HEALTH & EMERGENCY INFORMATION

MEDICAL INFORMATION

Special tour information