Passenger Information Passenger Information Form Name(Required) First Last Email(Required) Enter Email Confirm Email Phone Number (Mobile or Landline)(Required)Date(Required) MM slash DD slash YYYY Birthdate(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Tour You Are Interested in Booking(Required) I Am Paying:(Required) Deposit In Full Other Doctor's Name(Required) First Last Doctor's Phone Number(Required)Medications (list by brand name; include dosage if possible)(Required)Allergies (Example: Medications or Foods)(Required)Emergency Contact(Required) First Last Relationship to Passenger(Required) Emergency Contact's Phone Number(Required)Please list all health conditions we should know about.(Required)I Have Had the Covid-19 Vaccination.(Required) Yes No Are you celebrating a special occasion on this tour? (Example: Birthday, Anniversary, etc.) Let us know!(Required) Enter your full name below to indicate the following: I understand that Jane’s Journeys, LLC, as a tour operator, does not assume and cannot be held liable for personal illness, such as Covid-19 or personal injury, property damage or other loss that may occur as a result of negligent acts or omissions on the part of any supplier.(Required) First Middle Last EmailThis field is for validation purposes and should be left unchanged. You can download a copy of Jane’s Journeys LLC Passenger Information Form here.