Traveler Profile Please complete and submit form. All information is secure and will be kept confidential.Traveler 1: Name exactly as it appears on your Passport First Middle Last Suffix Address Street Address City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Phone - HomePhone - WorkPhone - CellPrimary Number Home Work Cell Email Trip Name and Date" Date of Birth Day Month Year Passport Number Passport Date of Issue Day Month Year Passport Date of Expiration Day Month Year Place of Issue TSA/Global Traveler Number Passport UploadAccepted file types: jpg, png, pdf, gif, Max. file size: 256 MB.Dietary Requirements and AllergiesIs there any additional information we should know?Please include medical conditions, mobility issues, &/or special occasionsNumber of Travelers123456789101112Please fill out as much information as you have on each passenger.Traveler 2Passport Information: Names must be exactly as they appear on PassportsName First Middle Last Suffix Date of Birth Day Month Year Passport Number Passport Date of Issue Day Month Year Passport Date of Expiration Day Month Year Place of Issue TSA/Global Traveler Number Passport UploadAccepted file types: jpg, png, pdf, gif, Max. file size: 256 MB.Dietary Requirements and AllergiesIs there any additional information we should know?Please include medical conditions, mobility issues, &/or special occasionsTraveler 3Passport Information: Names must be exactly as they appear on PassportsName First Middle Last Suffix Date of Birth Day Month Year Passport Number Passport Date of Issue Day Month Year Passport Date of Expiration Day Month Year Place of Issue TSA/Global Traveler Number Passport UploadAccepted file types: jpg, png, pdf, gif, Max. file size: 256 MB.Dietary Requirements and AllergiesIs there any additional information we should know?Please include medical conditions, mobility issues, &/or special occasionsTraveler 4Passport Information: Names must be exactly as they appear on PassportsName First Middle Last Suffix Date of Birth Day Month Year Passport Number Passport Date of Issue Day Month Year Passport Date of Expiration Day Month Year Place of Issue TSA/Global Traveler Number Passport UploadAccepted file types: jpg, png, pdf, gif, Max. file size: 256 MB.Dietary Requirements and AllergiesIs there any additional information we should know?Please include medical conditions, mobility issues, &/or special occasionsTraveler 5Passport Information: Names must be exactly as they appear on PassportsName First Middle Last Suffix Date of Birth Day Month Year Passport Number Passport Date of Issue Day Month Year Passport Date of Expiration Day Month Year Place of Issue TSA/Global Traveler Number Passport UploadAccepted file types: jpg, png, pdf, gif, Max. file size: 256 MB.Dietary Requirements and AllergiesIs there any additional information we should know?Please include medical conditions, mobility issues, &/or special occasionsTraveler 6Passport Information: Names must be exactly as they appear on PassportsName First Middle Last Suffix Date of Birth Day Month Year Passport Number Passport Date of Issue Day Month Year Passport Date of Expiration Day Month Year Place of Issue TSA/Global Traveler Number Passport UploadAccepted file types: jpg, png, pdf, gif, Max. file size: 256 MB.Dietary Requirements and AllergiesIs there any additional information we should know?Please include medical conditions, mobility issues, &/or special occasionsTraveler 7Passport Information: Names must be exactly as they appear on PassportsName First Middle Last Suffix Date of Birth Day Month Year Passport Number Passport Date of Issue Day Month Year Passport Date of Expiration Day Month Year Place of Issue TSA/Global Traveler Number Passport UploadAccepted file types: jpg, png, pdf, gif, Max. file size: 256 MB.Dietary Requirements and AllergiesIs there any additional information we should know?Please include medical conditions, mobility issues, &/or special occasionsTraveler 8Passport Information: Names must be exactly as they appear on PassportsName First Middle Last Suffix Date of Birth Day Month Year Passport Number Passport Date of Issue Day Month Year Passport Date of Expiration Day Month Year Place of Issue TSA/Global Traveler Number Passport UploadAccepted file types: jpg, png, pdf, gif, Max. file size: 256 MB.Dietary Requirements and AllergiesIs there any additional information we should know?Please include medical conditions, mobility issues, &/or special occasionsTraveler 9Passport Information: Names must be exactly as they appear on PassportsName First Middle Last Suffix Date of Birth Day Month Year Passport Number Passport Date of Issue Day Month Year Passport Date of Expiration Day Month Year Place of Issue TSA/Global Traveler Number Passport UploadAccepted file types: jpg, png, pdf, gif, Max. file size: 256 MB.Dietary Requirements and AllergiesIs there any additional information we should know?Please include medical conditions, mobility issues, &/or special occasionsTraveler 10Passport Information: Names must be exactly as they appear on PassportsName First Middle Last Suffix Date of Birth Day Month Year Passport Number Passport Date of Issue Day Month Year Passport Date of Expiration Day Month Year Place of Issue TSA/Global Traveler Number Passport UploadAccepted file types: jpg, png, pdf, gif, Max. file size: 256 MB.Dietary Requirements and AllergiesIs there any additional information we should know?Please include medical conditions, mobility issues, &/or special occasionsTraveler 11Passport Information: Names must be exactly as they appear on PassportsName First Middle Last Suffix Date of Birth Day Month Year Passport Number Passport Date of Issue Day Month Year Passport Date of Expiration Day Month Year Place of Issue TSA/Global Traveler Number Passport UploadAccepted file types: jpg, png, pdf, gif, Max. file size: 256 MB.Dietary Requirements and AllergiesIs there any additional information we should know?Please include medical conditions, mobility issues, &/or special occasionsTraveler 12Passport Information: Names must be exactly as they appear on PassportsName First Middle Last Suffix Date of Birth Day Month Year Passport Number Passport Date of Issue Day Month Year Passport Date of Expiration Day Month Year Place of Issue TSA/Global Traveler Number Passport UploadAccepted file types: jpg, png, pdf, gif, Max. file size: 256 MB.Dietary Requirements and AllergiesIs there any additional information we should know?Please include medical conditions, mobility issues, &/or special occasionsTraveler 13Passport Information: Names must be exactly as they appear on PassportsName First Middle Last Suffix Date of Birth Day Month Year Passport Number Passport Date of Issue Day Month Year Passport Date of Expiration Day Month Year Place of Issue TSA/Global Traveler Number Passport UploadAccepted file types: jpg, png, pdf, gif, Max. file size: 256 MB.Dietary Requirements and AllergiesIs there any additional information we should know?Please include medical conditions, mobility issues, &/or special occasionsInsuranceProtect your travel investment; In order to protect you and your trip investment, we recommend you purchase travel insurance. Travel Insurance is designed to cover losses from sudden and unforeseeable circumstances. Any monies paid are committed to secure your travel arrangements and are 100% non-refundable. Travel Insurance will help recover costs that could arise should changes or cancellations be required for insurable reasons, protecting both prepaid arrangements and covering unexpected additional costs. It is strongly recommended that insurance is purchased within 48 hrs of your deposit as funds are not protected until insurance is purchased. Alternatively, you may sign the attached waiver form indicating that you have adequate insurance or that you want to decline insurance. Please note that any excess expenses incurred or lost are your own financial responsibility. I have, or will be, purchasing insurance coverage from Civilized Adventures* Yes No Travel Insurance - Waiver of Coverage I have my own insurance that will cover me adequately. I would like to decline Travel Insurance. Provide Insurance name/policy number:Travel Insurance Waiver* I accept the Waiver of Coverage for insuranceCivilized Adventures recommended Comprehensive Travel Insurance and I have declined this insurance coverage for myself, and those family members travelling with me. I acknowledge that my travel agent, the agency, the insurance company and/or any of their staff will not be held responsible for any expenses that may be incurred because of this decision. Payment InformationThis form is being submitted from behind an SSL (Secure Socket Layer) to protect your information.Name as it appears on Credit Card First Middle Last Suffix Card Number Currency of Credit Card CAD USD Card Expiration MonthPlease enter a number from 1 to 12.Card Expiration YearPlease enter a number from 2020 to 2050.Billing Address (if different than initial address listed) Street Address City State / Province / Region Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency ContactName First Last Phone NumberRelationship to Traveler Frequent Flyer Programs*OptionalAirline/Status Name as it appears on membership First Middle Last Suffix Membership Number Add another Program? Yes No Frequent Flyer Program 2Airline/Status Name as it appears on membership First Middle Last Suffix Membership Number Add another Program? Yes No Frequent Flyer Program 3Airline/Status Name as it appears on membership First Middle Last Suffix Membership Number Add another Program? Yes No Frequent Flyer Program 4Airline/Status Name as it appears on membership First Middle Last Suffix Membership Number Airplane Travel Preferences*OptionalAirline Preferences Class Preferences First Class Business Premium Economy Economy Private Seat Preferences Aisle Window Center No Preference Other Other For Our Records*OptionalHow did you hear about us? Personal Network Virtuoso Website Walk-In Referral-Please note name in "Other" box Marketing Event-Please note which in "Other" box Other Accommodation Style: Boutique Hotels Chain Hotels Suites Condos/Villas Other Other ReleaseResponsibility Clause* I have read and agree to Civilized Adventures - Responsibility ClauseCivilized Adventures Inc., Trip leaders, and Agents notify you as follows: We strongly urge you to purchase travel insurance. Clients, together with their personal property including baggage, are at their own risk. Clients are wholly responsible for arranging their own insurance and ensuring that they are in possession of private Travel Insurance with protection for the full duration of the tour in respect of at least medical expenses, injury, death, repatriation, cancellation and curtailment, with adequate benefits. Clients making their own arrangements should ensure that there are not exclusion clauses limiting protection for the type of activities included in their tour. Whether clients choose to obtain Travel Insurance through Civilized Adventures or their agents, or through their own independent arrangements, the clients must satisfy themselves that any such insurance is what they require and clients should arrange supplementary insurance if need be. No refund will be made for unused services that are included in the price. Civilized Adventures shall not be liable for any delays, deviations, or omissions from any tour caused by circumstances beyond its reasonable control, nor for any direct or indirect consequences thereto. Civilized Adventures shall not be liable to compensate clients for associated expenses incurred as a result of their booking. Clients’ bookings are accepted on the understanding that they appreciate the possible risks inherent in adventure travel and that they undertake the tours featured in our program at their own volition. Due to political and cultural differences, as well as generally tougher physical conditions, travel to many areas of the world involves risks other than those we take in our daily lives. Civilized Adventures and the tour operators with which it works place extreme importance on the safety of clients. It is important, however, that clients realize that they are responsible for making themselves aware of the risks involved, and are responsible for making their decisions accordingly. Civilized Adventures Inc. reserves the right to refuse to accept or retain any person as a member of the tour at any time or to make changes in the published itinerary whenever, in their sole judgment, conditions warrant or if they deem it necessary for the comfort, safety, and convenience of this tour. The payment of the required deposit or any partial or full payment of a reservation on this tour shall constitute consent to all provisions of this condition list. The passage contract used by airline(s) concerned when tickets are purchased shall constitute the whole contract between airlines and the purchaser of this tour. I HAVE READ AND HEREWITH ACCEPT THE RESPONSIBILITY CLAUSE AS LISTED ABOVE, AS WELL AS THE ATTACHED RELEASE OF LIABILITY AND WAI VER OF CLAIMS AND RELEASE OF LIABILITY AND ASSUMPTION OF ALL RISKS.RELEASE OF LIABILITY AND ASSUMPTION OF ALL RISKS* I have read and agree to Civilized Adventures - RELEASE OF LIABILITY AND ASSUMPTION OF ALL RISKI,(names of listed travellers), acknowledge that I have voluntarily applied to participate on the trip designated on this application. Civilized Adventures is responsible only for their services. I am voluntarily participating on the tour or expedition with knowledge that travel to the foreign countries and/or remote areas visited by this trip involves numerous risks and dangers including, but not limited to: the forces of nature; civil unrest or terrorism or abduction; roads, trails, hotels, vehicles, boats or other means of conveyance which are not operated or maintained to Canadian standards; high altitude; animals and wildlife, including my interaction with them, voluntary or otherwise; diseases endemic to the area of travel; accident or illness without access to means of rapid evacuation or availability of medical supplies; the adequacy of medical attention once provided; physical exertion for which I may not be prepared; anything arising from my consumption of alcoholic beverages or use of drugs; or acts or omissions arising from inexperence or lack of knowledge on the part of the group leaders. I HEREBY AGREE TO BE RESPONSIBLE FOR MY OWN WELFARE, AND ACCEPT ANY AND ALL DAMAGES ARISING FROM DELAY , UNANTICIPATED EVENTS, ILLNESS, PERSONAL INJURY , EMOTIONAL TRAUMA OR DEATH OR DAMAGES TO PROPERTY. I VERIFY THIS STATEMENT BY CHECKING THIS BOX.My AdvisorGeneralDenell FalkKathy OakesJulie BatesAndrew De AngelisKylan FalkLena DojcinovicPlease select your advisor's name so your information can get to the right person. If you are not sure, please select General
