Galapagos Ultimate Wildlife Nature Cruise M/Y ERIC / LETTY /ORIGIN / THEORY Congratulations! You’ve signed up for a fantastic adventure in the Galapagos! To ensure your trip runs smoothly, please read everything in this packet very carefully. Please complete the enclosed Medical Form , Release of Liability, Travel Insurance Waiver, and Flight Itinerary, and return them to us within 2 weeks of receipt. TRIP CONFIRMATION: Dates of Trip: ________________________________________________ Traveler Name(s) Passport Country of Issue Passport # Expiration Date Date of Birth FLIGHT INFORMATION: Date & Time of Arrival in Ecuador: ___________ Date & Time of Departure from Ecuador: _____ Please list all flights and connections Airline / Date of Departure City Departure Arrival City Arrival Flight # Flight Time Time If you miss a flight connection, a flight is canceled, or you are otherwise going to be late : Relax and stay calm. We won’t leave you flat! Good communication, however, will enable us to take care of you. So if you will not make your scheduled pick-up, please call our California office at 415-524-8611 (our 800 number will not work from Ecuador). For additional emergency contact information, see page 17 of this packet. If you have to leave a message, be specific and include new flights, arrival times, and the phone number of a hotel where you can be reached if you have been delayed overnight. If you do not arrive on time, we will check to see if your flight was delayed and wait for you if it is a short delay. If your delay is lengthy, transportation will be arranged for you at an extra charge. Wild Planet Adventures partners with EcoVentura as part of the Galapagos Network to provide you with the best services in Ecuador. Bring this information packet with you. Check www.WildPlanetAdventures.com for more info on the Galapagos. 369 -B 3 rd Street #405 San Rafael, CA 94901 1-800 -990 -4376 [email protected] Today’s Date _______________________ CONFIDENTIAL HEALTH QUESTIONNAIRE Instructions (1) Applicant, with Parent or Guardian, completes and signs form (2) Please print and complete one health questionnaire per traveler. (3) IMPORTANT: Return completed form immediately to Wild Planet Adventures. General Information Trip Name _________________________________________________________________________ Your First & Last Name ______________________________________________________________ Address ___________________________________________________________________________ Home Telephone (____) ______________________ Cell Phone (_____) _______________________ Birthdate _____________ Present Age ________ M ( ) F ( ) Height _________ Weight __________ Family Physician ___________________________________________________________________ Physician’s Address and Telephone _____________________________________________________ Person to Notify in the Case of Illness or Injury ___________________________________________ Relationship _______________________________________________________________________ Address ___________________________________________________________________________ Home Telephone (____) ______________________ Cell Phone (_____) _______________________ Medical Information YES NO 1. Do you wear a medic alert tag? If so, what is it for? 2. Have you ever had a heart attack? 3. Have you ever been told by a doctor that you have high blood pressure, heart murmur or heart disease? 4. Do you experience anaphylactic shock from bee stings or other insects? 5. Have you ever had a seizure? 6. Do you have allergies to any environmental substances, foods, or drugs? If so, please specify: 7. Have you ever had Lung Disease? 8. Do you have any disabilities of back, hips, knees, or ankles? If so, please specify: 9. If you walked on level ground for one mile at an average pace, would you get out of breath, have pains in the chest, develop muscle fatigue, or have pains in your legs? If so, please specify: 10. Are you taking any medications prescribed by a physician? If so, please specify: 11. Is there anything about your current mental or emotional status that might affect your ability to participate? If so, please specify: 12. Are there any other medical reasons that you may be at risk by participating in activities on this trip? ( Note: Laughing to death does not count! ) If so, please specify: 13. Do you have any dietary restrictions? If so, are they mild preferences or serious lifestyle choices? Please specify: 2 369 -B 3 rd Street #405 San Rafael, CA 94901 1-800 -990 -4376 [email protected] 14. Have you had any of the following? If so, please state if they are ongoing or if one-time, state the year of occurrence: Asthma Epilepsy Malaria Tuberculosis Stomach Ulcer Diabetes Hepatitis Other Hernias Dislocations Fractures Concussions Sprains/Strains Any other injuries, illnesses or disabilities If you currently have any of the following symptoms or conditions, please circle “Yes,” underline and describe the problem. If not, circle “No.” 1. Dizziness, loss of consciousness, or recurrent headaches Yes No 2. Eye, ear, nose, throat or sinus symptoms Yes No 3. Impairment of sight, hearing, or speech Yes No 4. Chest pain, shortness of breath, palpitation, swelling of ankles, heart murmur or high blood pressure (at any time in your life) Yes No 5. Leg cramps, varicose veins or varicose ulcer Yes No 6. Sensitivities (allergies) to horse serum (tetanus antitoxin), sulfa, penicillin or other drugs, or other allergies Yes No 7. Symptoms related to the gastrointestinal tract, for example: recurring abdominal pain, diarrhea, passing of blood, etc. Yes No 8. Albumin, sugar or blood in urine; kidney stone or other urinary difficulties Yes No 9. Muscle, joint or back pain, bursitis, sciatica Yes No 10. Benign or malignant growth or tumor Yes No Please Initial: _______ I am aware that it is my sole responsibility to be aware of and care for my injuries, illnesses, abilities and limitations at all times. I will communicate clearly any problems or potential problems to the trip leader as soon as I am aware of them. PHOTOGRAPHY RELEASE I understand that photographs may be taken of me during this trip and used for promotional purposes. My signature below also gives my consent to be photographed and the images used to promote Wild Planet Adventures. I hereby grant and convey unto Josh Cohen/Wild Planet Adventures all rights, title and interest in any photographic images made by, for, or given to Josh Cohen/Wild Planet Adventures during the Wild Planet adventure in which I participate, including, but not limited to, any royalties, proceeds or other benefits derived from such photographs. ___________________________________________________________________________________________________________ Signature of Participant #1 Name (printed) Date ___________________________________________________________________________________________________________ Signature of Participant #2 Name (printed) Date 3 369 -B 3 rd Street #405 San Rafael, CA 94901 1-800 -990 -4376 [email protected] RELEASE & ASSUMPTION OF RISK Please Read This Carefully Trip: Galapagos; Trip Date: _________________________ Please read this Agreement carefully before signing as it is a legally binding contract. Each traveler must sign this form. A parent/guardian must sign for minors under 18 years old. Responsibility : Wild Planet Adventures, its owners, employees, agents, partners and assigns, acts only as an intermediary for its suppliers, assumes no responsibility for and cannot be held liable for any negligent or willful act or omission of any supplier or other third party, or for their financial insolvency, bankruptcy, or dissolution. A supplier’s services are subject to the supplier’s own terms and conditions, as well as the local laws and regulations of the relevant country. COVID-19 : I understand that the World Health Organization has declared the novel coronavirus, also known as COVID-19 to be a pandemic. I understand that Covid-19 is believed to be spread by person-to-person contact, which includes touching a surface that has been contaminated by an infected person. I also understand that someone, e.g., another participant, a tour leader or guide, or other third party could have COVID-19 but not show symptoms. As a result, governments and health agencies recommend mask wearing, and social distancing and have, in many locations, prohibited the congregation of groups of people. I understand that Wild Planet Adventures cannot guarantee that I (or any minor in my custody or care) will not become infected with Covid-19. Further, I understand that participating in activities offered by Wild Planet Adventures or using any of its equipment or property may expose or infect me or any minor in my custody or care. I understand that the risks relating to COVID-19, including contracting the virus, are inherent in my trip, and I assume those risks. I understand and agree that during the adventure program, guided trip, tour or any other activity in which I will participate, under arrangements of Wild Planet Adventures, LLC and its agents, employees, associates, affiliated companies and/or subcontractors, certain dangers and risks may arise, including, but not limited to, acts of God, the hazards of traveling in unsafe or politically unstable areas or under unsafe conditions, the dangers of civil disturbances, terrorism and war, the forces of nature and those arising out of the rigors required of any activities, explosion, flood, hurricane, tempest, tidal wave, earthquake,