Please Complete and Return with deposit to:
AVENTURAS PATAGONICAS - 1303 Sumac Ave - Boulder, CO   80304 USA
Toll Free: 888.203.9354 - International: 303.447.2858 - Fax: 303.417.0789

Name and date of trip:___________________________________________________________________

Name_________________________________________________________________________________

Address_________________________________City_____________State______Zip Code____________

Telephone_______________Email_____________________Age_______Height________Weight________

Occupation__________________________________________Passport #__________________________

In case of an emergency notify:
Name____________________________________Telephone_____________________________________

Address_________________________________City______________State________Zip Code__________

Do you have any allergies?______If yes, explain_______________________________________________

Are you taking any medication?_____If yes, explain____________________________________________

Are you a vegetarian?________________________

Medical History__________________________________________________________________________

_______________________________________________________________________________________

Outdoor Experience_______________________________________________________________________

_______________________________________________________________________________________

Climbing Experience (Peak, Route, Date)
Please complete this if you are signing up for a mountaineering or skiing expedition.

_______________________________________________________________________________________

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How did you first learn of Aventuras Patagonicas?______________________________________________

Signature_______________________________________________Date_____________________________