Name: Date: Tel. No: Fax No: E-mail:       Approx. date of Travel: No. of persons: If any children (ages): Where will you be Flying into/out of: Dar es Salaam Nairobi JRO       Type of Tour: Duration (in days): Destination: Preferred rooming: Single Double Triple       Extra services needed: Hotel Accom. needed before/after tour Shuttle reservations (Nairobi - Aru - Nbo) Airport transfers Domestic flight (Arusha/JRO to Zanzibar/Dar) Others( please specify):       Any other Inquiry/questions:   Physical/Medical Information I can jog without distress for: I can walk comfortably with a daypack for: I regularly follow a fitness program that includes (details): I have had the following illnesses or injuries in the past 12 months (details): I am on the following medication: (details): Any history of back or knee problems, heart or breathing condition, altitude sickness, diabetes, or any other conditions relevant to your enjoyment of the expedition? Are there any foods you cannot / do not eat? Are there any foods you love to eat? Are there any other health concerns you would like us to know about? In case of emergency, notify: Name: Tellephone: