Checking off your bucket-list, one trip at a time

Dolomites September 8 - 15 Travel Form

Personal Information

Name

First Name

Last Name

Birth date:

Age:

Country:

Cell Phone Number (with country code)

Emergency

Emergency Contact:

First Name

Last Name

Relationship:

Contact Number (including country code)

Arrival Information

Do you have a valid Schengen Visa?

YES

Date of Arrival to Venice Airport

YYYY

Time of Arrival to Venice Airport

(please include a.m. or p.m.)

Flight Number

Please add Flight Number arriving to Venice Airport

Departure Information

Date of Departure from Venice Airport

YYYY

Time of Departure from Venice Airport

(please include a.m. or p.m.)

Flight Number

Please add Flight Number departing from Venice Airport

Dietary Information

Food

Do you have any special dietary needs such as food allergies, low salt, low fat, low/no sugar, vegetarian etc.? Please be as specific as possible

List all of the foods that you just don’t like or tend to stay away from

Have any special breakfast item requests?

Fitness and Medical History

What is your physical fitness level?

How often do you exercise and what type of sport you like to practice?

Please list previous medical/psychological conditions which may affect your fitness level

Do you have any heart related conditions?

Please list any medications you are taking

Please list any medication allergies

Do you smoke? If yes, how often?

Please provide any additional information that may be useful to emergency medical personnel in the event of an emergency

DOLOMITES FORM