EmailMe Form - Traveler's Information

Salutation *

Name as it appears on your passport or required document: *

Prefix First Middle Last Suffix

Phone: *

### - ### - ####

Passport Information *

Passport Number
Passport Expiration Date
State/Country of Issuance

Date of Birth: *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email Address: *

Destination of Travel *

Type of Travel *

Date of Travel *

MM / DD / YYYY

Please provide the date of departure

How many days/nights

How long is your stay?

Price for your Trip: (please contact agency if this is unknown) *

$ Dollars . Cents

What is the name of your airport of choice? *

Are you a part of a Group?

I'm with a group (6 or more)

No, I'm not with a group

I am unsure

Lodging Occupancy *

Single Occupancy

Double Occupancy

Triple Occupancy

Are you an active Military member, a retired Veteran, or a First Responder? *

Travel Insurance-Travel insurance is a smart option and is highly recommend. It covers issues such as cancellation, delayed flight, and lost luggage. Please contact the agency for further details and costs. *

Please add travel insurance

No-I understand I am responsible for unforseen travel issues

Are you fully vaccinated? *

Yes, I am fully vaccinated.

I am partially vaccinated.

No, I am not vaccinated.

Please enter the dates you received your vaccinations. *

Do you have any dietary restrictions or food allergies? Please describe. *

Please list any medical conditions you have obtained. *

Are you currently taking any medications? Please list them. *

Do you have any Pre-Existing Conditions. Please list or type "N/A".

Are you currently undergoing any medical treatments? *

Your Shirt Size *

Emergency Contact Information *

First Last

Your emergency contact person (someone NOT traveling with you):

Relationship *

How is this person related to you:

Phone *

### - ### - ####

Emergency contact person's phone number:

Emergency Contact's Email

Name(s) of Person(s) Traveling/Lodging With You: *

(all travelers must fill out this form individually)

Attestation:
I, the traveler, agree that the above information is correct and accurate. I am aware that the information above must match the passport information completely and accurate. Failure to do so will result in denial of travel.

I understand that I am fully responsible for any charges incurred as a result of misspellings or inaccurate information and fines or charges incurred as a result of missing required information.

I further state that I fully understand and agree to the terms and conditions above. *

Place your initials in the box:

Name *

First Last