ONLINE BOOKING FORM

ELDER EXPEDITIONS, INC.
P.O. Box 474, Fortson, GA 31808-0474 (USA)
706-323-341-7858
Toll free from the U.S. and Canada: 1-877-92 ELDER (1-877-923-5337)
info@elderexpeditions.com
*Fields Required
Name*:
Email:
Address*:
(include postal code
and country)
Telephone Day:
Telephone Evening:
Telephone Cell:

For which event are you booking?
Destination (Country & region)

Travelling Companions
I am travelling alone and wish to share lodging
I am travelling alone and DO NOT wish to share lodging
(In this event the indicated single supplement is to be added to your payment.)
I am travelling with:
 
 
 

About You*
Sex: M   F
Date of Birth:
Participants who are over the age of 75 are required to submit the
Elder Expeditions Medical Certificate
height:
weight:
Describe the general
state of your health:
   
Within the last two years have you had any of the following:
Ankle injury Wrist injury Back injury
Heart or lung issues Asthma Angina
Diabetic.
If Yes Are You Insulin Dependent?Yes No
   
Describe any health issues of which
we should be aware or which will
impair your participation in any of
the listed activities:
Describe any allergies:
Describe any Dietary Restrictions:
   
  In what sporting activities do you participate?
Sport:
Frequency of participation
(daily weekly, monthly, on occasion):
Sport:
Frequency of participation
(daily weekly, monthly, on occasion):
Sport:
Frequency of participation
(daily weekly, monthly, on occasion):
   
*I have read and understand the Terms and Conditions as set forth in the
 Elder Expeditions website and agree to comply with the stated terms and conditions.
   
  Travel Insurance
  I have purchased travel insurance.
Name of Insurer:
Name of Insurance plan:
Travel Insurance Policy No:
My insurance plan provides:
repatriation (emergency medical transportation)
emergency medical / dental benefits
Trip interruption / cancellation by Elder Expeditions