Pre Trip Questionnaire

Main Information

Which Lodge(s) are you going to? (*)

Kau Tapen Lodge   Villa Maria Lodge
Pira Lodge   Suindá Lodge
Delta Fishing Trips   Northern Patagonia Lodge
Futa Lodge   Bair's Lodge
Abaco Lodge

Group Leader (*)

Personal Information

First Name(*):

Last Name(*):

Preferred Name

Email(*)

Birth Date (*)

Passport Number(*)

(Your passport must be valid for six months following the last day of your South American trip. If your passport expires before then,please renew it right away.)

Expiration Date(*)

Address(*)

Country(*)

State(*)

City(*)

Zip Code(*)

Phone

International Flights

Arrival Date:

Time:

Flight Number:

Company:

Arrival Airport:

Departure Date:

Time:

Flight Number:

Company:

Departure Airport:

Domestic Flights

Arrival Date:

Time:

Flight Number:

Company:

Arrival Airport:

Departure Date:

Time:

Flight Number:

Company:

Departure Airport:

Emergency Contact

Name(*):

Relationship:

Contact Number(*):

How can we make your trip better?

Do you have medical conditions or a dietary restriction?

Do you have any allergies?

Favorite drink(s)?

If you would like to borrow any loaner gear, please list your request here:

Security Code(*)

*Please answer the above security question so we know we are being contacted by a real person.

Main Information

Which Lodge(s) are you going to? (*)

Group Leader (*)

Category

Personal Information

First Name(*):

Last Name(*):

Preferred Name

Email(*)

Birth Date (*)

Passport Number(*)

Expiration Date(*)

Address(*)

Country(*)

State(*)

City(*)

Zip Code(*)

Phone

International Flights

Arrival Date:

Time:

Flight Number:

Company:

Arrival Airport:

Departure Date:

Time:

Flight Number:

Company:

Departure Airport:

Domestic Flights

Arrival Date:

Time:

Flight Number:

Company:

Arrival Airport:

Departure Date:

Time:

Flight Number:

Company:

Departure Airport:

Emergency Contact

Name(*):

Relationship:

Contact Number(*):

How can we make your trip better?

Do you have medical conditions or a dietary restriction?

Do you have any allergies?

Favorite drink(s)?

If you would like to borrow any loaner gear, please list your request here:

Security Code(*)