Booking Form
Please print all information
and mail to us. Use BLOCK CAPITAL throughout.
Mr.
Prem Singh / Mr. Tenzin Ningbo
POTALA ADVENTURERS
Village Siyal Manali – 175131,
Himachal
Pradesh. India
Tel:
0091 1902 251705
This is an agreement between
POTALA ADVENTURERS hereafter called the organizer and following people called CLIENTS:
PERSONAL DETAILS
Title:
Mr. / Mrs. I Ms
First Name:
________________________________________________________________
Last name:
__________________________________________as it appeared on passport
Sex:
______________________ Age ______________________________________
Name you like to be called:________________________________________________________________
Home Address: ________________________________________________________________
________________________________________________________________
City, State, Zip, Pin code: ________________________________________________________________
Nationality:
________________________________________________________________
Phone (H)
_________________________
(W) _____________________________
Fax No.
__________________________
Email:
________________________________________________________________
Occupation:
________________________________________________________________
Date of Birth:
________________________ Place of Birth:
____________________________
Passport No
________________________________________________________________
Issue date
______________________________Expiry date_________________________
Place of Issue
_______________________
Travel Insurance Name ________________________________________________________________
IMPORTANT
In Case of Emergency accident
Please Notify Supplement Name Address of Person Whom You Know
First Name:
_____________________ last name:
_______________________
Your relation:
___________________________________________________________
Address:
____________________________________________________________
____________________________________________________________
Tel No:
____________________________ Mobile No: __________________
Fax No.: ____________________________
Email: ____________________________________________________________
TRIP DETAILS
Name of trip / trek: _________________________________________________________
Leaving to trek on ______________________ arriving
at final destination on __________________
Thus comprising actual ___________ trekking days.
Guide Name
___________________________Horseman ____________________________
With ___________ horses. Or
with porters ________________________
Arrival Date in New Delhi:
Date:
__________________________ From: ________________________
Flight Name:
______________________
Departure Details from New Delhi:
Date:
__________________________ To
________________________
Flight Name:
____________________________________________________________
ADDITIONAL REQUIREMENTS
1. Are you Vegetarian / Non Vegetarian:
_____________________________
2. Allergic Health Problem if Any:
_____________________________
_________________________________________________________________
Previous Trekking / Climbing
Experience if Any: ______________________________
______________________________________________________________________________________
RELEASE OF LIABILITIES AND ASSUMPTION OF RISK
Please you must insure before commencing trekking,
travelling, adventure travel, climbing, any sorts of adventure activities are not risk free. There is risk of Altitude sickness
(AMS acute mountain sickness),
Where medical attention and evacuation may
not be available in remote area, injury and death caused by falling rocks, avalanches, crevasses, while crossing high passes, miss-step falling, land-slides, weather may change to extreme conditions huge snow-fall,
heavy rain, falling from temporary bridges, encounter with wild and domestic animal yak, Dzo, trekking horses/mules uncertainty
caused injury.
These injury or accident are possible if you
unaware of it however there are rare chances of injury cause guide and staff
are there for your utmost safety all during the trek and tour.
1. I accept that agency will not be responsible
for any accident that may occur during the trekking, or travelling.
2. I accept that agency will not be responsible
for any lost of personal nature during the trip.
3. I accept responsibility for my own welfare any and all risks that may arise in connection with this trip.
4. I accept and acknowledge that I am voluntary participating on this adventure travel trip.
I understood and state that I have read carefully
above given statement and safety while travelling, trekking or trek climb. There fore I assume full responsibility of myself,
any sorts of accidents injury, death or loss of personal belongings that occurs with me, POTALA ADVENTURERS, its owner and
their staff, employees, associates, suppliers and affiliated companies, will
not be responsible. I am fully in good physical condition and able to take part in this trekking tours organise by Potala
adventurers. The term hereof shall serve as release assumption
of risk for myself, my heirs, administrators, and executors and for all members of my family.
I ACCEPT THE RELEASE OF LIABILITIES
SIGNATURE ______________________________________________________________________________________
I have carefully read this
agreement and fully understand it’s contain. I am aware that this is a release of liabilities and contract between me
and Mr. Prem Singh of Potala Adventurers and or his affiliated organizations and signs it of my own free will. I also acknowledge
that I have carefully read Potala adventurers booking information and including its policy on cancelled trips and refund,
and agree to all stated conditions set forth in the booking information.
Signature
______________________________________________________________
Witness
_______________________________________________________________
Please mail
or fax a copy of this Booking Form and Condition of Contract to POTALA ADVENTURERS with your signature.
