Personal Information Form
Personal Information Form
Please fill the form for each person
Your Address
Your Address
Your Address
Your Address
Your Address
Hotel prior to embarkation
Hotel prior to embarkation
Hotel prior to embarkation
Hotel prior to embarkation
Hotel prior to embarkation
Hotel prior to embarkation
Hotel after disembarkation
Hotel after disembarkation
Hotel after disembarkation
Hotel after disembarkation
Hotel after disembarkation
Hotel after disembarkation
Travel insurance / emergency contact
Travel insurance / emergency contact
Travel insurance / emergency contact
Your emergency contact
Your emergency contact
Your emergency contact
Are you physically fit to participate in (long) walks ashore, to walk and move without assistance, including climbing stairs and the gangway, while being on board and also under unfavourable weather and sea- conditions and to embark and disembark an inflatable small boat (Zodiac) used at sea for shore-based transfers?
Do you have any current medical illnesses that have required regular care of a doctor?
Do you have any current disabilities or infirmities?
Have you been hospitalized or had surgery in the last five years? If so, when, and for what?
Do you have any heart or respiratory problems?
Are you a diabetic?
Do you have any dietary restrictions? If so, what are they?
Do you have any food allergies? If so, what are they?
Do you have any drug allergies? If so, what are they?
Do you have any physical or mental limitations, handicaps or prosthesis?
Do you have difficulty in walking or use crutches, a cane or wheelchair?
Do you have a medical background (i.e. doctor, surgeon, nurse)?
Are you pregnant? If so, how far will you be in the pregnancy at time of travel?
Just one step to your dream vacation!
Fill out your contact details below and receive your personalized offer and a detailed action plan within 30 minutes.
Onboard m/v Plancius, m/v Ortelius and m/v Hondius we provide the use of rubber boots for all passengers for free. If you are unsure of your boot size or if your boots do not fit, you can exchange them for other boots while on board. We have more than enough boots to accommodate all sizes.
Made on
Tilda