EARTH RIVER FUTALEUFU RESERVATION FORM

I/We wish to register for the following trip: MAGPIE DEPARTURE DATE: ____________________________

DEPOSIT ENCLOSED: __ person(s) at U.S. $1,000 per person per tour (visa &master card accepted) Total: $______

CREDIT CARD# _______________________________ EXP. DATE ________

VCODE: ______

I wish to have a single room whenever possible, with a single supplement charge(Yes or No). __

I wish to secure a roommate (Yes or No). _____

I am a: __smoker __non-smoker

NAME(S):____________________________ and _____________________________ ADDRESS: ______________________________________________________________ TELEPHONE: HOME ______________________ Cell  _____________________

E-MAIL: ________________@_________________ Reservations accepted are subject to the Terms and Conditions, the Liability and Assumption of Risk Release below, and the Responsibility Acknowledgments on second page, and confirmed only if presented to Earth River Expeditions, Inc. on this form signed by each tour member, and accompanied by the required deposit. ITINERARIES AND TOUR RATES ARE SUBJECT TO CHANGE DUE TO CIRCUMSTANCES BEYOND OUR CONTROL. I/We are on good health and capable of walking driving and traveling trough rough terrain. By signing below I certify that I do not have any condition or disability that would create hazard for my self or other passengers. _________________________________________ Signed Date _________________________________________ Signed Date

PLEASE PRINT OUT THE FOLLOWING FORMS AND MAIL THEM BACK TO OUR OFFICE. WE REQUIRE ORIGINAL SIGNATURES FOR OUR FILES. EARTH RIVER EXPEDITIONS 180 TOWPATH ROAD, ACCORD, NEW YORK 12404