This booking form can be used for both guests or tour operators / travel agents alike. The key thing to note is that before traveling with Summits Africa all the key data must be sent in BEFORE the trip starts. As this information is collected primarily on safety grounds we reserve the right to decline your booking should the information not be filled out in full. Some information is NOT mandatory but we request that each and every guest fills out the form as fully as possible to help us ensure you have a successful and safe trip.

Note for Tour Operators and Travel Agents: this form can be incorporated into your own site (the form section only), if required. Please contact our technical team for more info.

1. Guest Information

Trip or trips joining - write trip name (s) and start dates(s)
First Name
Last Name
Date of birth
Email Address
Telephone or cell phone
Height (indicate feet & inches or meters & cm)
Weight (indicate lbs or kg)
Passport Number
Address
City / Town
State / County
Country
Zip code / Post code
Day time telephone
Evening telephone
Fax
If sharing a room please indicated who with

2. Emergency Contact

First Name
Surname Name
Relationship
Day time telephone
Evening telephone
Cell phone
Email Address
Fax

3. Insurance information

Comprehensive insurance should be purchased before travelling to Africa. Please check in detail your medical coverage before you depart for your trip. If you do require medical attention in Africa you will be required claim expenses back from your insurance company. It is a very good idea to have some emergency cash on hand for emergency scenarios (rough guide $500)

Please tick the box that applies to you:

 I have comprehensive insurance I do not have comprehensive insurance
Insurance reference number
Emergency contact telephone
Any other instructions
Fax

4. Medical & Dietary Information

Allergies (if none write none in allergy 1)

Allergy 1
Allergic reaction 1
Medication required 1
Allergy 2
Allergic reaction 2
Medication required 2
Allergy 3
Allergic reaction 3
Medication required 3
Other allergic reactions, medication or information

5. Medication (prescribed and non prescribed)

Medication 1
Medication 1 is taken for
Medication 1 dosage
Medication 1 start date
Medication 1 known side effects
Medication 2
Medication 2 is taken for
Medication 2 dosage
Medication 2 start date
Medication 2 known side effects
Medication 3
Medication 3 is taken for
Medication 3 dosage
Medication 3 start date
Medication 3 known side effects
Other Medications, taken for, dosage and side effect information

6. Medical history current and past (please select yes or no)*

I have had a seizure within the last 2 years  Yes No
Hospitalisation / emergency room / urgent can in the past 2 years  Yes No
History of heart attack, bypass, rhythm abnormality  Yes No
Medical device (hearing aid / prosthetic device)  Yes No
Orthopedic problem, neck, back, ankle or knee  Yes No
Currently pregnant  Yes No
Asthma  Yes No
Diabetic requiring medication  Yes No
Organ (s) removed - is yes please indicate which one (s)

7. Heart Risk Assessment*

Diagnosed high blood pressure, even if controlled  Yes No
Smoker  Yes No
Abnormally high cholesterol level  Yes No
Family history of heart attack, bypass, sudden unexplained death before 60  Yes No
Unexplained chest pain, shortness of breath, heart palpitations, sweats  Yes No
Fainting spells, dizziness  Yes No

8. Activity Log

Any of our trips involving hiking, mountain biking or other strenuous activity requires that participants be reasonably fit. Please indicate below regularly performed exercise activities. For safari only trips it is not necessary to fill out this section.

Activity + Frequency / time / distance / intensity

9. Arrival & departure details

Arrival in East Africa

Departure from East Africa

Date of arrival in East Africa
Port / airport of arrival
Airline & Flight number
Time of arrival
Date of departure from East Africa
Port / airport of departure
Departure Airline & Flight number
Time of departure

10. Preferences & special interests

Where ever possible we will always try to cater for specific preferences or interest such as bird watching, animal behaviour or cultural interests. Please let us know any additional information below.

Drinks preference
Other preferences
Additional information

Terms and conditions

I have read Summits Africa Terms and conditions  Yes No