Passenger Information

Name:

Date:

Birthdate:

Cell Phone Number:

Email Address:

Address:

City:

State:

Zip Code:

Tour You Are Booking:

I am paying:
A DepositIn Full

Doctor's Name & Phone Number:

Allergies (Example: Medications or Foods):

Emergency Contact Name:

Relationship to Passenger:

Emergency Contact Phone Number:

Medications (list all by brand name, include complete dosage information):

Please list all health conditions we should know about:

I have had the Covid-19 vaccination:
YesNo

Special birthday or anniversary you are celebrating during this tour:

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.

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