Registration Step 2 of 3

This form is the second step to your registration. Once you have submitted this section, please print out the NOTICE AND RELEASE form, and return to info@nahanniwild.com.

Once we have received your information, we will contact you to complete your registration.

PLEASE NOTE: Separate registration documents are required for each participant. 


Name *
Name
Address *
Address
Home Phone *
Home Phone
Work Phone
Work Phone
Date of Birth *
Date of Birth
Sex *
Emergency Contact
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Address
Emergency Contact Address
Emergency Contact Cell Phone *
Emergency Contact Cell Phone
Emergency Contact Home Phone
Emergency Contact Home Phone
Trip Cancellation and Extended Medical Insurance
We strongly recommend that you purchase additional insurance and that you review our cancellation policy. *
Medical Information
Please rate your health *
Please rate your own physical fitness *
Please rate your own swimming ability: *
Are you affected by any of the following *
Please bring duplicate prescriptions.
Other Travel Info
Discounts
Please select the following that apply:
Additions
Equipment
(required for calculating aircraft payload)
(required for calculating aircraft payload)
We provide BARE 2mm Shorty Sport Wetsuites for all our participants. Please refer to their website for sizing information. www.baresports.com
Drink Preferences
Please input the number of cups you would consume.
Does your trip overlap any special dates? Please check: