1. Birthday
2. Passport #
3. Exp. Date
4. Gender MaleFemale
6. Languages

1. An initial $500 deposit is required to participate in one of the trips with EXPLORE Peru Payment plan are available, and it runs until 60 days prior the departure, the participant can enroll to a payment plan without extra fees and doesn’t need to pay for their trip all at once. All major credit cards from Visa, Mastercard, American Express are accepted, to avoid the 3.75% credit card fees, please consult the electric transfers options and Apps available: Venmo, PayPal, CASH by Square or send a personal check to:
   EXPLORE Peru 11175 South O’henry Rd, Sandy UT 84070 REGULATION AND CONDITIONS:

1. Before I can participate, required forms and payments must also be submitted.

1. I will be flexible, patient, and foremost, keep a sense of humor. I understand that the Tour Leader will give their best efforts and will need my support. I will also abide by the code of conduct requiring exemplary behavior and consideration for others.

1. Insurance and risk: I am responsible for my health and belongings; travel insurance is not included in the cost of the trip and it is up to me to determine the sufficiency of my insurance. EXPLORE Peru is not responsible for the cost of medical care or any loss/damage incurred during or as a result of this expedition.

1. Cancelations: Once the deposit is submitted along with this form, should I decide not to go for any reason, all booked airline tickets and any other booked fees paid by EXPLORE Peru for travel become partial non-refundable. To the extent that deposits have not been spent and/or refunds can be obtained, EXPLORE Peru upon request will refund the funds, less any penalties incurred by the Peruvian provider services. Full payment is due at least 60 days prior to departure, unless notified otherwise. Funds become nonrefundable at that time.

1. In-country cancellations as a result of disruptions, which are out of EXPLORE Peru control, are non-refundable at any time.

1. Once I have been accepted as a participant of the trip, I understand I need to read the expedition Itinerary given to me and attend any coordination meetings organized by the Tour Leader. It is my responsibility to complete and to submit the travel application.

1. Contact Name
2. Relationship
3. Address
4. City, State, ZIP
5. Phone Number
6. Email
7. In case of an emergency, I understand that I am responsible for my own health and care, including evacuation if necessary.

1. Health Care Provider
2. Policy Holder Name
3. Account Number
4. Provider phone # (24 hour # if possible)

Check if you have or have had any symptoms in the following areas to a significant degree and briefly explain.

1. Anxiety
2. Asthma
3. Bladder/ Kidney Problems
4. Blood Clot
5. Cardiac/Heart Problems
6. Cancer
7. COPD/Pulmonary Problems
8. Circulation
9. Kidney Stones
10. GI/Stomach Problems
11. Hypertension
12. Liver Disease
13. Migraine Headaches
14. Diabetes
15. Stroke
16. Seizure Disorder (Epilepsy)

1. Explain reason for marking any of the listed items above:

1. Tetanus
2. Chicken Pox
3. Pneumonia
4. Influenza
5. Hepatitis A
6. Hepatitis B
7. MMR

1. Have you tested positive for TB and if so, when? YesNo
2. TB Test Date

1. Have you ever had a blood transfusion? YesNo

EXPLORE Peru shall not be liable for any death, nor for any damages or claims arising from negligence of any person. I do for myself, my heirs, executors, and administrators, release and forever discharge EXPLORE Peru, and all other persons or legal entities connected in any way or manner with, acting officially or otherwise, from all claims, demands, actions, or causes of action, on account of my death or on account of any injury, sickness or otherwise, which may occur to me from any cause during this trip or any continuation of it or resulting from it. I further agree that I will not sue, seek to sue, or make any claim for any damages whatsoever, for anything which is related, however remotely, to this trip, against EXPLORE Peru or any other person or legal entity connected in any manner with the Peru Expedition.

1. I agree to the terms and conditions as presented above
2. Sign (ALL CAPS)
3. I confirm my child (under 18 years old) is able to attend.
4. Legal Guardian Sign (ALL CAPS) if under 18