Registration Form

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* Required Fields

Personal Info

Group Name			Today's Date
Your Name* (Exactly as it Appears on Passport)			Nickname
Age	Date of Birth		Passport No.
Passport Exp. Date		All USA and Canadian passport expiration dates cannot be within 90 days of expiring to travel to Costa Rica. For other nationalities please check with embassy.

Home Address*

City*

State*

Zip*

Phone Number*

Fax

Email Address*
Departure City*

Dates of Travel*

Emergency Contact Info

Emergency Contact*
Relationship to You*
Phone Number*
Address*

Please Answer These Questions
Any specific medical issues (including any allergies)?* yes no

How is your physical condition?

Do you have any dietary issues?* yes no

What are you most looking forward to about your Costa Rican Adventure?

How did you hear about us?

Have you signed the waiver?* yes no

(Thank you and we look forward to seeing you in the near future! Please send your deposit to the address below. You may include this form with your deposit, submit it electronically by clicking the "Submit" button above, or fax it separately to the number below. Feel free to Contact Us with any questions or comments.)

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Costa Rican Adventures
2002 Addison Street
Suite 202
Berkeley, CA 94704
Phone: 800-551-7887
Fax: 510-649-0212
requests@costaricanadventures.com