	Your Name
	Your Age
	Daytime telephone
	Mobile number
	e-mail address
	Departure Date
	Note: Please fill in a separate form for each family member


	Destinations & Duration VERY IMPORTANT ! Please tell us ALL your destinations and the time in days you will be there
	Holiday type i.e.hotel, adventure, backpacking
	Will you be..	Staying in rural areas? sleeping in the open/rough?
	Doing any risky activities like rafting,diving, sports?
	Spending time at high altitude ie trekking or climbing
	How high and for how long?


	Do you have any medical problems? ie Diabetes, Asthma, Heart disease
	Are you on any medication? What is it?
	Are you pregnant? yes no	Have you ever had fits? yes no
Tick any previous immunisations. Leave blank if not sure