FOR OFFICE USE ONLY
Date received <empty>
Date of trip <empty>
Travel specialist <empty>

# UNCHARTED OUTPOSTS
SAFARI & TRAVEL CO.

PERSONAL & MEDICAL INFORMATION FORM

PERSONAL INFORMATION
Name (as appears on your passport): <empty>
Mailing Address: <empty>
City: <empty>
Zip: <empty>
Home Telephone: <empty>
Fax: <empty>
Occupation: <empty>
Business Telephone: <empty>
ext.: <empty>
Business Fax: <empty>
Email Address: <empty>
Height: <empty>
Weight: <empty>
Age: <empty>
Birthdate: <empty>
M/F: <empty>

PASSPORT INFORMATION
Passport Number: <empty>
Nationality/Citizenship: <empty>
Date of Issue: <empty>
Date of Expiration: <empty>

EMERGENCY CONTACT INFORMATION
Name: <empty>
Relationship: <empty>
Telephone: <empty>
Address: <empty>
City: <empty>
Zip: <empty>

Please describe your Health and Medical history: <empty>
Any other medical conditions we should be aware of: <empty>
Allergies or dietary restrictions (vegetarian?): <empty>
Please list any alcoholic preferences (local beer, wine, domestic spirits). Please note that we will try our best to provide your drink of choice. <empty>
Describe the nature and extent of your camping, hiking, horseback riding, or other outdoor experience: <empty>
Please list any special occasions while on your trip: <empty>

DOCTOR INFORMATION
Name: <empty>
Address: <empty>
Telephone: <empty>
City: <empty>
Zip: <empty>