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RESERVATION & PERSONAL INFORMATION FORM

Please complete this form and mail with your applicable deposit (If you are paying by credit card)
made payable to:
WORLDWIDE ADVENTURS INDIA
The full completion of this form is MANDATORY for each trip – 1 form per person

Trip Name:               India
Name               Sex              
Street Address:               City/Town:
Province/State:               Postal/Zip code:
Telephone:( Home)                  Telephone:(Work)
Email Address:                Fax:
TripDate:                Country
Date of Birth(mm/dd/yy)
Occupation(If retired,please enter past profession):
MEDICAL INFORMATION:
If you have any of the following medical conditions , currently or a history, please check them off:
Diabetes Heart condition Cancer Asthma Joint ailments
Phobias Allergies Memory loss Recent surgery
If you have any other physicalor emotional limitations that would impact your ability to participate fully    
in this trip, please list them
Are you onany medication ? Please list
Smoker          Non-Smoker      
SPECIAL DIETARY REQUIREMENTS :
Vegetarian     Diabetic   Low-fat & Sodium   Gluten-Free   Other 


In case of Emergency, Please contact: (Please tell your contacts that you have given us their names)

1. Name :   Tel: Work :     Tel:Home:

2. Name :    Tel: Work :      Tel:Home:

Deposit $:                                                                                                             Cheque, Money Order, Bank Draft:          MasterCard:    Visa:   
Credit Card Numbe :        Expiry Date :
Cardholder Name ( as it appears on the Card )  :
Cardholder Signature :       Date: 
Please also Charge my credit card for :
 My Balance Payment for the tour (Due ninety days before the tour begins )
                                In US $:                              In Canadian $:

** PASSPORT INFORMATION ** 

Passport # :               Nationaliry                      :
Issued At   :               Issue Date ( mm/dd/yy)  :
                                                                       Expiry Date ( mm/dd/yy):
Your passport should be valid for at least 6 months beyond the expected date of your return home.


In completing this form, I affirm that I am in general good health, capable of performing the required exercise to participate, and that I have not recently been treated for, nor am I aware of, any condition that would jeopardize myself or other members of this tour. I accept as my personal risk the hazards of such participation, and will not hold Worldwide India. or its representatives responsible. I confirm that I am over the age of 18 and hereby release and forever discharge Worldwide India., its officers, directors, servants and agents from any liability whatsoever arising as a result of my participation in this trip, and I declare this release is binding upon me, my heirs, executors and assigns. I agree that this agreement shall be governed in all aspects by, and interpreted in accordance with, the law of Ontario, Canada.


I have read the Detailed Itinerary and the Terms & Conditions as outlined in the current Itinerary. I also understand that the unique nature of this type of travel involves accommodations, transport, safety and medical facilities not found on a conventional vacation.
Pls note Worldwide Adventures India is a land operator based in India. Shall not be responsible for any loss, damage, injury, or any inconvenience resulting from different living standard and practices outside North America.