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TOUR INFO   Choose your preferred trip departure: ☐ John of God - June 6-18, 2016 ☐ John of God - October 3-15, 2016 TRAVELLER INFO Your Name: ____...
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Choose your preferred trip departure: ☐ John of God - June 6-18, 2016 ☐ John of God - October 3-15, 2016 TRAVELLER INFO Your Name: ____________________________________________________________ Street Address: _________________________________________________________ City: __________________________________________________________________ Province or State: _______________________________________________________ Country: _______________________________________________________________ Cell Phone: ____________________________________________________________ Home Phone: ___________________________________________________________ Work Phone: ___________________________________________________________ Email Address: __________________________________________________________ EMERGENCY CONTACT Name: ________________________________________________________________ Email Address: __________________________________________________________ Phone: ________________________________________________________________ Address: _______________________________________________________________ Relationship to you: ______________________________________________________ ACCOMMODATION Accommodation is based on single occupancy with private bath. ☐ I am able to walk up one flight of stairs ☐ I prefer to have a room on the ground floor ☐ I am in a wheelchair

  TRAVEL & MEDICAL INSURANCE ★ Medical insurance is a mandatory requirement if you are travelling outside of your country. ☐ I am travelling outside of my country and agree to purchase Medical Insurance ☐ I agree to provide proof of health insurance within 30 days of the trip start date. Email copy to [email protected] ☐ I agree to bring a copy of my health insurance documents with me to Brazil. You will need to provide this to our guide at the Welcome Meeting on Day 1 of the tour. ★ Cancellation insurance is not mandatory but is strongly recommended to protect you against cancellation fees and additional travel expenses that may incur before, after, or during the trip. INNOCULATIONS Travel clinics can advise whether you will need inoculations prior to departing on your journey. PASSPORT & BRAZILIAN VISA ★ It is your responsibility to contact your local Brazilian embassy or consulate for the most up-to-date visa requirements for your nationality. ★ Please note that some countries require your passport to be valid for at last 6 months from the start date of your journey otherwise they can refuse your entry. ★ Obtaining a Brazilian visa may take several weeks so be sure to start the process as far in advance as possible. ☐ Yes, I understand and assume all responsibility for obtaining a valid passport, inoculations, and a Brazilian Visa (if required). PASSPORT INFO ★ Please ensure that the information in this section pertains to the passport that you will be travelling with. Your Name (As it appears in your passport): ___________________________________ Passport Number: _______________________________________________________ Nationality: ____________________________________________________________ Date of Birth (DD/MM/YYYY): ______________________________________________ Place of Birth: __________________________________________________________ Date of Issue (DD/MM/YYYY): _____________________________________________ Place of Issue: __________________________________________________________

  TRAVELLING WITH THE GROUP ☐ I understand and agree that if I arrive or depart on days different from the scheduled group arrival or departure days that I am responsible for transportation costs to/from the airport and Abadiânia. MEDICAL INFORMATION Please list all conditions (physical, mental, emotional) that you are being treated for by a medical doctor, other health care practitioner and/or professional at this time. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

Please list all physical, mental and/or emotional challenges that you are dealing with that have not been treated but for which you are concerned about. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

  Please list all medications you are taking that have been prescribed by medical doctors and/or health care practitioners and/or professionals AND all medications that may have been prescribed but that you have chosen not to take. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ SPECIAL NEEDS I require the following special arrangements to be made for me during my stay in Brazil (i.e. wheelchair, oxygen, special diet, allergies etc.): ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

*Please note, that while our guide will make every effort to ensure the ease and comfort of group members, a personal assistant (for whom an application form must also be completed) must accompany persons requiring frequent/constant care.



If there's anything else you think we should know about you please note it below.

______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

PREPARATION ☐ I agree to review the Casa Guide Book which will be sent to me by Original Routes along with the Confirmation Package. PERSONAL PRACTICE Please tell us about your spiritual beliefs and whether you have a meditation practice.

______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ HOW DID YOU HEAR ABOUT THIS JOURNEY? ☐ Original Routes website ☐ Original Routes social media ☐ Hollyhock social media ☐ Hollyhock catalogue ☐ Word of mouth from: ___________________________________________________ ☐ Other: ______________________________________________________________



☐ I understand that at no time did Original Routes or their agents promise or imply any cure of the participant's medical condition. This trip is undertaken by the free will of the undersigned without pressure by the Company or its agents. ☐ I understand and agree that Original Routes is not responsible for any health conditions or ailments contracted prior to, during, after or as a result of this journey. By booking a tour with Original Routes, you are agreeing to the Cancellation Policy & Terms & Conditions listed on the website. ☐ I have read and accept the Cancellation Policy ☐ I have read and accept the Terms & Conditions ______________________________ Signature ______________________________ Date Please email/scan this form to [email protected] Thank you!

Original Routes [email protected] (778) 588 7070 Vancouver, British Columbia, Canada

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