Peru Registration Stage 2 In order to complete your registration, we just need a little more information. Please scroll down and fill out the form so we can learn more about you: If you have trouble with this form or have additional questions, you can contact Laura by email at firstname.lastname@example.org or 1-800-611-5144 (toll free in the US and Canada). Peru Registration Form Personal InformationFirst Name*Last Name*If you selected a double occupancy room, do you have a roommate in mind? Do you want us to find you a roommate? If a roommate cannot be found for you, you will be placed in a single occupancy room and you'll pay the $985 for a single supplement with your final payment on January 15th, 2021.*Passport InformationIn the spaces below, enter your name exactly as it appears on your passport, as well as your passport number, the country that issued the passport, and the expiration date. (Your passport needs to be valid for six months beyond the time of our trip). If you’re in process of renewing your passport, just tell us in the box below!Your Passport First Name(s)Your Passport Surname(s)Passport NumberPassport Expiration DateCountry That Issued Your PassportIf you are in the process of renewing your passport, please give details below:Coming to the Amazon?If you have already put down your deposit for the Amazon extension trip, great! If you have not, are you still considering adding the Amazon extension to your trip? Yes, I’m still thinking about whether to add the Amazon extension. No, I wish I could, but I can’t take you up on the Amazon extension. Do you want us to reserve you two nights at Casa San Blas for the time between the end of the main trip and the Amazon Extension (May 28 and 29)? Yes, please reserve my room. I acknowledge that $250 for a single occupancy room (or $125 for a spot in a double, if one is available) will be added to my final balance for the retreat. I will make my own reservations for lodging during these two days. Learning More About YouWhat's Your Birthdate?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your Occupation?*Hobbies and Interests?*Describe your previous travel experience.*Have you ever traveled with a group before? If so, describe your experience.*Are you a smoker?*Please describe your health, noting any allergies, injuries, physical limitations you have. Please list the medications you take as well as anything else that might impact your participation in the trip itinerary. (A more detailed medical information form will arrive with your confirmation materials).*Are you physically able to manage stairs and walk two miles unassisted?* Yes No The itinerary of this trip includes several hikes and a fair amount of walking. Describe yourself as a hiker.*Have you had any health issues while traveling to higher altitudes in the past?*Do you have any dietary needs, restrictions, or allergies we should be aware of?Are you interested in obtaining CEUs (a small fee will be added to your final payment)? Yes, I would like to earn CEUs. No, I am not interested in CEUs. In case of emergency, who should we notify? Please include all contact information.*Learning Still More About You.How did you learn about this trip?*What are your reasons for wanting to join us in Peru? What do you hope to get out of this journey?*Regardless of where you’re flying from, we recommend booking your flight with our travel agent Linda to help coordinate logistics. Would you like to work with Linda?*InsuranceTravel Insurance*Because of requirements from our local vendors in Peru, travel insurance to cover any medical expenses incurred during this trip is required for this trip. In addition to medical travel insurance, we highly recommend that you choose an insurance plan that covers trip cancellation in case illness or injury prevents you from going on the trip. Your initial deposit for this trip is not refundable and further refunds are only available on a graduated basis according to our cancellation policy. Trip cancellation insurance is the best way to protect your investment. Recommendations about insurance will be sent after you register.I understand. I will purchase my own travel insurance within the next two weeks.I will contact your agent about helping me find the right travel insurance for me in the next two weeks.