! ! ! ! !
Name___________________________________________________________________ Billing Address___________________________________________________________ City____________________________________State________________Zip_________
! Phone___________________________________ ! E-Mail__________________________ !
Personal Medical Information will only be used in the event of an emergency Birthday (MM/YYYY) _______________Gender (M/F) ____Pregnant (Y/N) ______ Height_________________Weight_____________ Emergency Contact Person_________________________ Relationship_____________________________________Phone___________________
! Health Insurance______________________________Policy Number________________ !
List Any and ALL Pre-Existing medical conditions (asthma, knee, back, neck problems, allergies, etc.) Any pre-existing medical conditions must be approved by tour doctor with a note. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Would your doctor approve of you participating in this activity (Y/N)____________
Please note that at anytime during the tour if your guide determines that this trip is above your ability due to conditions or due to your fitness, he or she will attempt to adjust, or if needed, end the trip for your health and safety. There will be no refund or credit issued in the event that the trip is changed.
Aspen International Travel Company, Inc. prohibits discrimination on the basis of race, color, national origin, sex, religion, age, disability, political affiliation, or family status. Persons believing they have been discriminated against should contact the Secretary, U.S. Department of Agriculture, Washington, DC 20050, or call (202) 720-7327.
Published on Apr 6, 2014