Please submit
ONE
form per each individual traveler.
If changes are required, please submit a NEW
form and
check the Revision
or Cancellation
block below
Trip:
Form Status:
Original Revision
Cancel My Reservation
Traveler Information
Name:
As Shown On Passport
Travel Identification:
Passport is
required.
Please
enter your passport information below:
Number:
Expiration Date:
You are responsible for providing the proper travel identification
documents to board the airline and/or to enter the country and reenter
the US.
Home Phone:
Include Area Code
Home Address:
City:
State: Zip:
E-Mail Address:
Room Information
For any
"Side Trip" and/or "Rest-Day" locations please select "Room Type" for first
person in each room. If you are the second or subsequent person in
the room, indicate that in the "Room Type" blocks and fill in "Rooming
With" block. If
you are a single, the club will try to match you with a roommate unless you
indicate you will pay the "single rate".
Room Type:
Smoking
NOYES
Rooming With:
Travel Information
There is no Club Group Air
available for this trip. Please use the sample trip itinerary on
the main page to secure your own travel arrangements.
Transportation:
Optional Side Trip:
Side trip to
Sacha Lodge. Please check one
block below. No, I will not be taking the Side Trip
Yes, Include me on the Side Trip
Dive Information
Are You a Diver:
YES NO
Do You Want Nitrox:
YES
NO
Do You Need Rental Gear
YES
NO
Additional Information
Optional
Shirts Available:
Please pick Style and Size below. You are welcome
to order as many shirts as you want which will be added to your trip fees.
$10.00 for a T-Shirt, $28.00 for a Polo
Shirt.
Polo Shirts
"T" Shirt
Comments:
or Additional Information:
Submit Form:
Please be patient - Form may take a short time to process - You will
see a confirmation page when complete. You may want to print this
page for your records.
Important: After submitting your
reservation, please return to the Galapagos trip information page to select the
"Dive Trip Waiver" form button. Please print out or copy one
form per person, fill out and return to the club.
