•  Y o u   a r e   a t   S t e p  2  •

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X P E D I T I O N S   2 0 1 2
R E G I S T R A T I O N    F O R M
T H E   P A T H  OF  L I G H T

Once completed please consider buying Travelers Insurance

Registration Form (one per person) : Complete and click "Submit" once finished
Your Full Name:
Your E-Mail:

Your Passport Number :

Your Age:

Your Birthday:


Which trip(s) is this for?
Your Home Phone Number:
Your Cell Phone Number:
Place your complete address here:


E M E R G E N C Y    C O N T A C T    I N F O
Contacts Name:
Street Address :
City, State, Postal Code :
Country:
Best Contact Phone Number :
Best Contact Cell Phone Number:
Relationship To You :

 

 
A C C O M M O D A T I O N     P R E F E R E N C E
Single or Double?   Single       Double
Would you like us to arrange a roommate if possible?   Yes       No
 
M E D I C A L
Please explain below if you are currently under a doctors care, need special care, or use ANY medications. If so, please l them:

 

 
Have you purchased Travel Insurance?   Yes       No
If not, do you intend to?   Yes       No  (This is required. You must purchase travel insurance within 15 days of your deposit)
 
Is there something special you are hoping to see or do? Also indicate within this area which trip(s) this form is for.

 

 
E L E C T R O N I C    S I G N A T U R E

With your electronic signature you assure us you have read and completely understood the "Tour Information" section and the" Terms and Conditions" section, and you completely agree. Additionally, if you decide to participate in the Ayahuasca Ceremony you are required to sign a release form available here (right click to download). Blank release forms are also available once you arrive to the jungle lodge.

We will not accept anyone who has not completely filled out, signed and submitted this application.

An electronically signed application and your deposit must be received to secure your space on this trip.

You are responsible to have a valid passport that does not expire within the next 6 months!

 

 

 

 

 

Sign Here
(Enter your name EXACTLY as it appears on your Passport):
 

IMPORTANT: Email us a current photo of yourself: Xpeditions@Mac.com

 

 


  • Trip begins and ends in Iquitos, Peru
  • No international airfares are provided
  • No domestic airfare is included (Lima/ Iquitos/ Lima)
  • All prices are quoted as per person, double occupancy based on a minimum of 10 passengers
  • Single rooms are available for an additional $150
  • Tips and airport taxes are your responsibility
  • Once completed you should buy Travelers Insurance


You may send a certified check as payment to:
(payable to)
Jerry or Kathy Wills
1227 E. Hermits Lane
Cottonwood, Arizona 86326
 602 604 0212