searchtel 01904 500094 firstname.lastname@example.org
Please take the time to ensure that this information is accurate as we will use this information to book portions of your tour. Lost Earth Adventures cannot be held responsible for any problems that arise due to this form being completed incorrectly.
Please give us your chosen trip name:
Date of your chosen activity (dd/mm/yyyy):
Please give us the name of your group organiser (lead name):
Your first name (as written on passport):
Your middle names - If applicable (as written on passport):
Your surname (as written on passport):
Date of Birth (dd/mm/yyyy):
Mobile telephone number:
Confirm email address:
Street Name and Number:
Place of issue:
Name of Emergency Contact:
Relationship of Emergency Contact to you:
Emergency Contact Telephone number:
Please describe and detail any medical condition you have and any precautions you need to adhere to (if none, write none):
If you are on or are required to take any medication please list the name of the medication you take, the required dosages and times it is needed to be taken (if none, write none):
Please tell us your weight (important):
Please tell us the height of the participant (important):
Optional: Additional Information:
Please list anyone who is accompanying you:
How did you hear about us? ---Google or other search engineRecommendationLeaflet or brochurePosterAdvert in magazineArticle in the pressMet our team at an eventReferral from other websiteThrough an agentSocial mediaOther
By submitting this information you are hereby agreeing to our Terms and Conditions available to see on our website here: Terms and Conditions and confirm that you have read them and the trip dossier for your trip. Please tick the box if you agree.
If you have any trouble reading the Terms and Conditions or if there is anything about them that you do not understand then you must call us on 01904 500094 and we will be able to send you a copy or explain them to you in more detail. Please do not submit this form until you have read, understood and agreed to our Terms and Conditions.
By submitting this form you agree to the following statements:
I will pay any applicable single supplement (unless you are content with sharing a room with a member of the same sex or your travelling partner).
I confirm that I will pay the amount quoted for each person by no later than 60 days prior to departure, and that this also applies to any single supplement which might be due.
I confirm that I will the pay the costs of any extras by no later than 60 days prior to departure
I understand that I will not be allowed to travel without sufficient travel insurance.
I confirm that I will provide Lost Earth Adventures my insurance policy details including the company name of the insurer, the policy number and emergency contact details of the insurers before I depart on my chosen tour.
I confirm that I will fully declare to my insurers the nature of this trip accordingly.
Mailing List If you would like to be sent exclusive deals and details of our new up and coming adventures, please tick this box to be included in our mailing list. We promise to never send you more than 12 emails a year.
THIS FORM WILL NOT HAVE SUBMITTED UNLESS YOU HAVE ANSWERED EVERY QUESTION ABOVE. YOU WILL RECEIVE A THANK YOU MESSAGE ONCE IT HAS SUBMITTED SUCCESSFULLY.
Thank you for choosing Lost Earth Adventures. We hope you will find your holiday rewarding and fun.
Copyright ©2019 Lost Earth Adventures, All Rights Reserved. Lost Earth Adventures is a Limited Company Registered in England No. 7455734. VAT No. 234433135.