Wilderness Adventure Reservation Form

1. Your email address:
   
2. Home Phone:
   
3. Work Phone:
   
4. FAX:
   
5. First Name:
   
6. Last Name:
   
7. Mailing Address:
   
   
8. City:
   State:
9. Country:
   Postal Code:
10. I wish to participate in the following program:
    
11. Name of Trip:
    
12. Departure Date:
    
13. I have enclosed the deposit sum of:
    
14. The balance owing (60 days prior) is:
    
15. The number of persons travelling with me is:
    
16. I have the following handicaps or physical conditions that require special attention:
    
17. I have the following special diet requirements:
    
18. Please provide a name, address, phone, and your relationship of a person we can contact in case of an emergency:
19. 
    
20. I prefer smoking: non-smoking
    
21. Birthdate:
    
22. Additional comments or questions for "Tundra Tom"
    

Note: Each indiviudal will be required to sign a Mandatory Release and Assumption of Risk