Galapagos 2021 Registration OLD ONE--DO NOT USE

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January 10-20, 2021

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

It is important we have your exact passport name, as we will be buying flights on your behalf. If the name on the ticket does not match the name on your passport, the ticket may not be honored!

Preferred name (or nickname)

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

YYYY

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

Best phone number to reach you *

Just in case we need to get ahold of you more quickly than via email in an emergency.

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!

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 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 let you know if others are in a similar situation. 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 have a roommate, do you prefer one big bed or two separate beds? (*Please note that hotels in Ecuador often have 2 big beds, regardless!)

1 big bed

2 separate beds

Doesn't matter

Clear selection

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

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

Food allergies (gluten, dairy, etc) / Dietary restrictions (vegetarian, vegan, don't eat fish, etc).

Any health conditions/allergies (food, drug, or environmental) we should be aware of? Are there any medications you will need refrigerated or medical devices that require electricity?

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

Yes.

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

Are you comfortable walking short distances over rocks? (See example photo) *