Galapagos March 2024 Registration

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Full Name (Please write your name *exactly* as written in your Passport) *

Preferred name (or nickname)

Email address *

We communicate exclusively by email in preparation for this journey, so please make sure you give us your best email and then add us to your address book.

Home Address (please include street address; city; state; ZIP; country) *

Best phone number to reach you in an emergency before the trip *

Date of Birth (month, date, and year format) *

YYYY

Passport country of issue *

Expiration date of passport (please see note below regarding expiration date) *

Please know that to enter Ecuador your passport must have at least six months validity beyond the end of the trip and at least two blank pages.

YYYY

Will you have a single room or a shared room on this trip? *

If you are willing to share but don't have a roommate already, we can connect you to other guests also looking for a roommate. However, we can't guarantee that you will have a roommate.

I have a roommate but want separate beds

I have a roommate and will share a bed

I do not want a roommate and will pay the single supplement

I do not have a roommate but would like a roommate (though I understand if a roommate cannot be found I will have to pay the single supplement)

If you are sharing a room, what is your roommate's name?

Would you prefer a room on a lower floor at hotels vs. a higher room with potentially a better view? (Some of our hotels can have up to 3 floors and no elevator. We'll bring your luggage up to your room, so no worries on that front.) *

Yes, please put me on a lower floor

I'm ok with higher floors.

Other:

Update: Both the upgraded rooftop room and the interior rooms have been claimed already. If you're interested in one of them should there be a cancellation, please let us know!

I would like the rooftop room if there is a cancellation

I would like an interior room if there is a cancellation

Other:

Clear selection

Hobbies/Interests/Occupation; we'd love to know a little about you and this will also help us suggest activities and sites for you. *

Emergency contact information *

Name; Relationship; Phone Number; Email. Please make sure your emergency contact is someone who is not joining you on this journey.

Dietary restrictions (vegetarian, gluten, dairy, etc. Please mention if you do not eat fish) *

If any of this should change before the start of the trip, please let us know as soon as possible.

Any health conditions/allergies (food, drug, or environmental) we should be aware of? Any allergies you carry an EpiPen for? *

Are there any medications you will need refrigerated or medical devices that require electricity? *

How comfortable are you swimming? Have you ever snorkeled before? *

Are you interested in the optional Española Island excursion (details and price in the blue boxes at the bottom of the trip website)? *

Yes, definitely!

No, thanks.

I'll think about it, but I understand that space is limited to 12 guests.

Other:

I have read the Suggested Fitness Requirements section of the website. *

Yes.

Are you comfortable walking short distances over rocks? (See example photo) Walking sticks are available for rent if needed (or you can bring your own). Please note that is only applicable for parts of 1-2 excursions; you can see other sample photos on your trip website under "Suggested fitness requirements." *

What are you hoping to experience on this journey? How can we help you get the most out of your time with us? *

I acknowledge that there may be specific COVID-19 protocols that must be adhered to, such as mask-wearing, hand-washing, and social distancing, in the spirit of keeping myself, fellow guests, and locals safe. Noncompliance with these measures will result in not being able to continue on the journey. *

I agree.

Please read and sign the Tour Contract and Liability Waiver below. You can download a copy of this contract for your records at http://bit.ly/retreatourscontract2021

I agree to the Tour Contract and Liability Waiver *

I agree

Required

Please sign below with your digital signature which consists of your full name. *

Example: John Q. Sample

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