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Critical Information Form
Please help our travel procedures go smoothly for us all by providing the information to the following questions. Questions related to health are in case of emergency care or treatment. All enclosed information will be treated confidentially by your group leaders; however, submission of this information constitutes permission to pass along your food restrictions to our restaurants and to share medical information with qualified medical or other persons vital to your health and well being.
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Please select the journey you are part of in 2024:
Camino de Santiago – April, 2024
Southern Spain – April/May, 2024
Contemplative Ireland AH – August, 2024
Contemplative Ireland – September, 2024
Tuscany/Umbria – October, 2024
Contemplative Photography Retreat, Spain – October, 2024
Please select the journey you are part of in 2025:
Contemplative Ireland, Binkley – April, 2025
Camino de Santiago – May, 2025
Republic of Georgia – June, 2025
Northern Spain: Culture and Cusine – August, 2025
Contemplative Ireland – September, 2025
Tuscany/Umbria – October, 2025
Name as it appears on your passport
*
First
Middle
Last
Date of Birth:
*
Address
*
Street
City
*
City
State
*
State
Zipcode
*
Zipcode
Cell Phone
Home Phone
Email
*
Passport
*
Number
Passport Issue Date
*
Date of Issue
Passport Expiry Date
*
Expiry Date
Passport Place of Issue
*
Place of issue
Arrival Flight Info
*
Arrival Airline
Flight Number
*
Flight Number
Arrival City
*
Arrival City (Which city are you arriving in?)
Arrival Day
*
Arrival Day
Date of Arrival
*
Date of Arrival
Arrival Time
*
Arrival Time
Travel details you'd like us to know? Please describe below:
*
Departure Flight Info
*
Departure Airline
Departure Flight Number
*
Departure Flight Number
Departure City
*
Departure City (Where are you traveling from?)
Departure Day
*
Departure Day
Date of Departure
*
Date of Departure
Departure Flight Time
*
Departure Flight Time
Travel details you'd like us to know? Please describe below:
*
Name of a family member we can contact in an emergency
*
First
Last
Family member's Address
Address
Family member's Phone Number
*
Phone Number
Name of another person we can contact in an emergency
*
First
Last
Emergency Contact's Address
*
Address
Emergency Contact's Phone Number
*
Phone Number
Primary Physician
*
Name
Primary Physician's Phone Number
*
Phone Number
Health Insurance
*
Insurance Company
Health Insurance Group ID
*
Group ID
Health Insurance Issuer ID
*
Issuer ID
Health Insurance Phone Number(s)
*
Phone Number(s)
Please describe any potentially life-threatening medical conditions
Please describe any allergies to medications
Do you have any food allergies?
*
Yes
No
List of food allergies
If yes, please list them here
Other details we need to know regarding any allergies:
Any other details we need to know regarding your allergy/allergies? i.e. Will you be carrying an EPIPEN that we need to be made aware of in case of an emergency?
Do you have any significant food restrictions?
*
Yes
No (I eat anything!)
If yes, please specify:
Please choose an option
Vegan (no animal products including dairy, meat, poultry, fish, or eggs)
Vegetarian (I do eat dairy and eggs, but no meat, poultry or fish)
Pescatarian (I do eat fish, eggs, and dairy, but no meat or poultry)
Gluten Free
Dairy Free
Other (please specify below)
What else would you like us to know about your diet?
Please be specific
Any other information you would like us to have in the event of an accident or emergency?
Please email any supporting documents, if needed.
Submit
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