RESERVATION FORM TRIP FUTALEUFU RAFTINGVENTANA RAFTINGMAGPIE RAFTINGPRIMROSE RAFTINGPATAGONIA HIKING DEPARTURE DATE I WISH TO HAVE A SINGLE ROOM WHENEVER POSSIBLE, WITH A SINGLE SUPPLEMENT CHARGE(YES OR NO)YESNO I WISH TO SECURE A ROOMMATE (YES OR NO) YESNO NAME * HEIGHT WEIGHT GENDER MALEFEMALEOTHERS DATE OF BIRTH PASSPORT# EMAIL ADDRESS* IN CASE OF EMERGENCY CONTACT:NAME RELATIONSHIP ADDRESS DAY PHONE EVENING LIST ALL MEDICATIONS CURRENTLY BEING TAKEN AND WHY LIST ALL ALLERGIES IS THERE A HISTORY OF ALLERGIES TO INSECT STINGS IN YOUR FAMILY?YESNO IF YES, WHO AND WHICH INSECT IF YOU ARE ALLERGIC, WILL YOU HAVE MEDICATION WITH YOU? DATE OF MOST RECENT TETANUS SHOT HAVE YOU EVER SUFFERED FROM: (answer Y or N) ANEMIA:YESNO EPILEPSY:YESNO DIZZINESS:YESNO CHEST PAIN:YESNO APPENDECTOMY:YESNO KIDNEY AILMENT:YESNO SEVERE INFECTION:YESNO SEVERE MENSTRUAL CRAMPS: YESNO JOINT INJURY/DISEASE: YESNO HEAD INJURY W/ UNCONSCIOUSNESS: YESNO DO YOU WEAR CONTACT LENSES? YESNO BONE INJURY: YESNO FAINTING: YESNO BACK PROBLEMS: YESNO DIABETES: YESNO DIGESTIVE PROBLEMS:YESNO HERNIA: YESNO ARE YOU A VEGETARIAN?YESNO LIST ANY DIETARY RESTRICTIONS/ PREFERENCES ARE YOU A SMOKER? YESNO PLEASE ELABORATE ON THE ABOVE OR ANY OTHER MEDICAL PROBLEMS(INCLUDE DATES AND CURRENT CONDITION) PLEASE EXPLAIN YOUR CURRENT EXERCISE ROUTINE, IF ANY(Please elaborate)
