Emergency Contact & Medical Questionnaire

Today's Date(Required)

Name of Tour Participant(Required)

Name of Tour(Required)

Start Date of Tour(Required)

Name of Emergency Contact at Home(Required)

Relationship to you(Required)

Emergency Contact Phone Number(Required)

Emergency Contact Email

Travel Insurance Provider(Required)

Policy Number(Required)

Travel Insurance Medical Emergency Phone Number (outside UK)(Required)

CONFIDENTIAL HEALTH INFORMATION: For WildWings use only.

This information is required to enable us to try to ensure that appropriate treatment is provided in the event of an emergency during the tour.

General Health / Mobility(Required)

Medications taken on regular basis and conditions to which they relate

Allergies / Dietary Restrictions

FLIGHT INFORMATION

(including connecting flights)

Flight booked through Sacha Barbato (Travel Counsellors)(Required)

Yes

1. Outbound Flight Number (first leg)

Departure Airport

Arrival Airport

Departure Date

Departure Time

Arrival Date

Arrival Time

2. Outbound Flight Number (second leg if applicable)

Departure Airport

Arrival Airport

Departure Date

Departure Time

Arrival Date

Arrival Time

3. Outbound Flight Number (third leg if applicable)

Departure Airport

Arrival Airport

Departure Date

Departure Time

Arrival Date

Arrival Time

Inbound Flight Number (first leg only)

Departure Date

Departure Time

Pre-tour and Post-tour Arrangements

If you are arriving ahead of the start date of the tour or staying beyond the end of the tour, please provide details of your initial arrangements such has hotels or onward transport.

Any additional information you think could be relevant

Comments

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

Emergency Contact & Medical Questionnaire

FLIGHT INFORMATION

Quick Links

Tours

Company Information

Financial Protection