AMAZON CONSERVATION ASSOCIATION

Emergency Information

Dear Visitor,

To ensure you a safe visit to Los Amigos and to provide assistance in case of emergency we ask that you please complete this form. Please note that this information is confidential and will only be released in case of emergency.

Thank you and enjoy your stay,

ACA

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Name:__________________________________________________________________

Address:

Home Phone:

E-mail:__________________________________________________________________

Date of Birth:

Passport No. & Place of Issue:

Insurance policy plan & contact information:

Please mark with X

No

Yes

Please explain

I am allergic to certain foods

I require a special diet

I am a vegetarian

I am allergic to a type of medicine

I am allergic to insect bites

I have a heart/respiratory condition

Please indicate any other dietary/health restrictions

In case of emergency please notify:

Name:__________________________________________________________________

Relationship:_____________________________________________________________

Home Phone:____________________________________________________________

Work Phone:____________________________________________________________

E-mail:_________________________________________________________________

Address:________________________________________________________________