AMAZONIA EXPLORATIONS: Rio Negro Walt Anderson & Mark Riegner, Leaders

June 5-16, 2018

PERSONAL INFORMATION FORM & LIABILITY RELEASE

Please complete this form and mail with your deposit & reservation form

to Walt Anderson

2911 E Granite Gardens Drive, Prescott AZ 86301

(928)308-9017;

The full completion of this form (2 pages) is essential for each trip – 1 form per person

Name: ______Male Female

(Please show name exactly as it appears in your PASSPORT)Title: ______

Address: ______City/Town: ______

Province/State: ______Postal/ZipCode: ______Country: ______

Telephone: Home (____) Work (____) Cell ( )

Email:______

Date of Birth: (mm/dd/yyyy)______

Occupation (if retired, please enter past profession): ______

MEDICAL INFORMATION:

If you have any of the following medical conditions, currently or a history, please check them off & explain:

 diabetes heart condition cancer asthma  joint ailments

 phobias allergies ______ memory loss recent surgery

If you have any other physical or emotional limitations that would impact your ability to participate fully in this trip, please list them: ______

Are you on any medications? Please list: ______

This trip is for non-smokers.

SPECIAL DIETARY REQUIREMENTS:

 vegetarian diabetic low-fat & -sodium gluten-freeOther: ______

______

In case of Emergency, please contact: (Please tell your contacts that you have given us their names)

1. Name: Tel: W (___)______H (____)______or

2. Name: Tel: W (___)______H (____)______

DEPOSIT $900.00 US -- Check, Money Order, or Bank Transfer. No credit card payments.

A deposit is required to guarantee your space on this tour. We will refund your deposit, less $100 handling fee, if you cancel prior to March 1, 2018. Fees are not refundable after March 1, 2018 unless trip is cancelled by us. We will bill you for the balance depending on what discounts you may be eligible for, whether or not you need a single supplement, or a small-group surcharge if enrollment is low (not anticipated).

Please make your final payment by US $$ personal check or bank transfer.

my Balance of Payment for the tour (due March 1, 2018)

my single supplement ($600, if applicable, due with balance of payment)

Special interests (circle): mammals; birds; plants; general nature; photography; local culture; other (please add)

Please do not book your flights until the trip is confirmed as operating.

**PASSPORT INFORMATION ** we will not be able to send your Final Documents until we have received this information

Passport #: ...... Nationality: …...... ………..

Issued at: ...... Issue Date (mm/dd/yy):...... ………..

Expiry Date (mm/dd/yy):…...... ………………

Your passport should be valid for at least 6 months beyond the expected date of your return home.

Liability Limitation --- Amazonia Explorations June 5-16, 2018

Walt Anderson, MarkRiegner, Amazonia Expeditions, and local guides and cooperating agents aim to provide every participant a safe, educational, and enjoyable experience. We act solely as agents for you regarding accommodations, special activities, and travel, by any means, and assume no liability for any act, error, omission, injury, loss, delay, mishap, or damage to persons or property arising from any cause during the course of the trip or in transit thereto. We can accept no responsibility for losses or additional expenses due to delay or changes in the services to be provided. We reserve the right to change our arrangements should conditions necessitate or to cancel any aspect of the trip due to exceptional circumstances. We also reserve the right to decline to accept or retain any passenger if, at our sole discretion, we determine that the presence of that person would be detrimental to the tour. If a participant is removed from a tour, our only obligation is to refund portions of fees unused and recoverable by the vendor(s). In the event that we deem it necessary to cancel the tour, we will provide a full refund that the participant acknowledges as full and final settlement.

As there is always an element of risk in any adventure associated with the outdoors, participants must read this form and the detailed itinerary carefully. This liability release will certify that the participant is physically fit, capable of participating in outdoor activities, and fully and completely aware of any associated risks created by field locations, including dangers related to water travel; boats; snakes; ants and biting insects; hazards of walking in steep, rough or muddy terrain; other transportation; and weather.

By joining this tour to the Amazon, I acknowledge that I have read the above information concerning responsibility and release MarkRiegner, Walt Anderson, local guides, and any cooperating agents from any liability. We will assume no liability for injury or death, illness, or loss of personal property or expenses thereof associated with tour participation. I also give permission for Walt Anderson, MarkRiegner, and Amazonia Expeditions to use any photos of me for promotional or commercial use.

SIGNATURE: ______DATE: ______

Note: U.S. citizens are required to have a visa to enter Brazil. Please allow enough time.