I/We wish I to register for the following expedition: FUTALEUFU BASE CAMP TRIP
DEPARTURE DATE: ____________________________
DEPOSIT ENCLOSED: __ person(s) at U.S. $600 per person per tour (visa &master card accepted) Total: $______
CREDIT CARD# _______________________________ EXP. DATE ________ VCODE: ______
__I wish to have a single room whenever possible. __I wish to secure a roommate.
I am a: __smoker __non-smoker
NAME(S):____________________________ and _____________________________
ADDRESS: ______________________________________________________________
TELEPHONE: HOME ( )______________________ BUS.: ( ) _____________________
E-MAIL: ________________@_________________PASSPORT #:
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.
180 TOWPATH ROAD, ACCORD, NY, 12404
(800)-643-2784 (845)626-2665 (845)626-4423-Fax
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