Personal Information Form
Personal Information Form
Please fill the form for each person
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Title
Mr
Ms
First name
Middle name
Last name
Date of Birth
Place of birth
Nationality
Passport number
Passport number
Country of issue
Place of issue
Date of issue
Date of expiration
Country
Your Address
City
Your Address
State
Your Address
Street
Your Address
ZIP/POST code
Your Address
Phone number
Email address
Hotel name
Hotel prior to embarkation
City
Hotel prior to embarkation
City
Hotel prior to embarkation
Check in
Hotel prior to embarkation
Check out
Hotel prior to embarkation
Reservation number
Hotel prior to embarkation
Hotel name
Hotel after disembarkation
City
Hotel after disembarkation
City
Hotel after disembarkation
Check in
Hotel after disembarkation
Check out
Hotel after disembarkation
Reservation number
Hotel after disembarkation
Travel insurance name
Travel insurance / emergency contact
Policy number
Travel insurance / emergency contact
Contact phone no.
Travel insurance / emergency contact
First name
Your emergency contact
Last name
Your emergency contact
Contact phone number
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?
Yes
No
Do you have any current medical illnesses that have required regular care of a doctor?
Yes
No
Do you have any current disabilities or infirmities?
Yes
No
Have you been hospitalized or had surgery in the last five years? If so, when, and for what?
Yes
No
Do you have any heart or respiratory problems?
Yes
No
Are you a diabetic?
Yes
No
Do you have any dietary restrictions? If so, what are they?
Yes
No
Do you have any food allergies? If so, what are they?
Yes
No
Do you have any drug allergies? If so, what are they?
Yes
No
Do you have any physical or mental limitations, handicaps or prosthesis?
Yes
No
Do you have difficulty in walking or use crutches, a cane or wheelchair?
Yes
No
Do you have a medical background (i.e. doctor, surgeon, nurse)?
Yes
No
Are you pregnant? If so, how far will you be in the pregnancy at time of travel?
Yes
No
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Full name
Phone number
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Bubber boots size for each person
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.
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Made on
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