Galapagos Tour - Medical/Dietary Information & Waiver Form

You will be traveling to a foreign country (Ecuador) on this tour that may lack some of the advanced medical facilities that you are accustomed to in the United States. In addition you will be traveling by small boat to the relatively remote island archipelago of the Galapagos, where there may not be quick access to medical facilities and professional medical care. In fact, advanced life support may take hours to reach. In our effort to help manage the risks associated with delayed care, you can help us by answering some personal medical questions, as well as abiding by our recommendations. The Samba carries first aid gear and a satellite phone for emergency purposes. In addition I am a certified Wilderness First Responder

Name*

First Last

Email*

Emergency contact name*

First Last

Relationship to emergency contact*

Emergency contact phone*

City/State/Country of emergency contact*

City State / Province / Region Country

Arrival Flight Information

Arrival Date*

Flight #*

Airline*

Time*

:

Departure Flight Information

Departure Date*

Flight #*

Airline*

Time*

:

Questions

Do you have a history of heart problems?*

Do you have a history of seizures?*

Do you have a history of asthma?*

Are you allergic to any substances?*

Do you have a history of anaphylaxis?*

Do you have a history of altitude sickness?*

Do you have any other medical condition that we should be aware of?*

Further Explain Questions

If you answered yes to any of the above questions, please describe your condition more thoroughly here. Specifically, we would like to know how well managed the condition is; whether or not you take medications for the condition; whether or not you have any side effects from the medication; and the last time you had to visit an emergency room as a result of the condition.

Our Recommendations

We recommend that you consult your physician if you answered yes to any of the above questions. Your doctor may be able to offer advice regarding whether or not this trip is appropriate for you, and he or she might be able to offer advice regarding whether or not you should modify your activities, daily routine or your medications. We recommend that you abide by all of your existing medication regimes, and that your medication routine remain uninterrupted immediately prior to as well as during your tour. If for some reason, you choose to alter your existing medication routine, please let us know.

Dietary Questions

It's important for us to know if you have any dietary restrictions, food allergies, or dietary preferences. Please answer the below questions - all are required. If it doesn't pertain to you just write "None".

Dietary Restrictions*

i.e. Vegan, Vegetarian, Gluten-free etc.

Food Allergies*

Dietary preferences*

Waiver

I have read through all of the trip information for the Galapagos tour, including the trip description and I understand that medical facilities and professional medical care may be more than a few hours away while traveling in the Galapagos. I consider my physical condition sufficient to participate in this trip, and I also realize that there are risks inherent when engaging in physical activities in such remote locations. I therefore do not hold Hugh Rose liable for circumstances beyond his control.

Name*

First Last

Typed Signature*

Date*

Phone

This field is for validation purposes and should be left unchanged.