Safari Registration

Safari Registration Form

Traveler's Information

First Name *

As it appears on your passport

Middle Name

As it appears on your passport

Last Name *

As it appears on your passport

Preferred Name

What name would you like to be called if different from your passport

Email *

Gender *

Date of Birth *

Month Day, Year

Day Phone *

Occupation

Passport Number *

Passport Country of Origin *

The Issue Date of Your Passport *

Month Day, Year

Passport Expiration Date *

Month Day, Year

Address *

Address Line 2

City *

State or Province *

Postal Code *

Country *

Height (in feet & inches)

Weight (in pounds)

Used for private charters/helicopters

Emergency contact not traveling with you *

Your relationship to this person *

Emergency contact's phone number *

Do you plan to purchase Travel Insurance?

Yes

No

Travel Insurance Disclaimer *

I do not plan to purchase Travel Insurance and I understand Barking Zebra Adventures' cancellation policies. I will not be entitled to a refund from Barking Zebra for any unused services due to a trip delay or cancellation, and that any costs associated with the trip delay, lost or delayed baggage and or medical services and hospitalization are my responsibility.

Are you allergic to any medications?

Yes

No

Allergies to medications

Do you have any other known allergies? (Food, Air-born, etc.)

Yes

No

Known allergies

Do you have any dietary requirements?

Yes

No

Dietary Requirements

Will you be taking any medications during this trip? *

Yes

No

Will you be taking any medications during this trip?

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