Book A Trip

This booking form can be used for both guests or tour operators / travel agents alike. The key thing to note is that before travelling with Summits Africa all the key data must be sent in BEFORE the trip starts. As this information is collected primarily on safety grounds we reserve the right to decline your booking should the information not be filled out in full. Some information is NOT mandatory but we request that each and every guest fills out the form as fully as possible to help us ensure you have a successful and safe trip.

Note for Tour Operators and Travel Agents: this form can be incorporated into your own site (the form section only), if required. Please contact our technical team for more info.

If you are making an enquiry then please use the Enquiry Form.

* is a required field

1. Guest Information
Trip or trips joining - write trip name (s) and start dates(s)	*
First Name	*
Surname / Last Name	*
Date of birth	*
Email Address	*
Telephone or cell phone
Height (indicate feet & inches or meters & cm)	*
Weight (indicate lbs or kg)
Passport Number	*
Address
City / Town	*
State / county	*
Country	*
Zip code / Post code
Day time telephone
Evening telephone
Fax
If sharing a room please indicated who with

2. Emergency Contact
First Name	*
Surname	*
Relationship	*
Day time telephone	*
Evening telephone
Cell phone	*
Email
Fax

3. Insurance information Comprehensive insurance should be purchased before travelling to Africa. Please check in detail your medical coverage before you depart for your trip. If you do require medical attention in Africa you will be required claim expenses back from your insurance company. It is a very good idea to have some emergency cash on hand for emergency scenarios (rough guide $500) Please tick the box that applies to you:
I have comprehensive insurance
I do not have comprehensive insurance
Insurance reference number	*
Emergency Contact telephone	*
Any other instructions
Fax

4. Medical & Dietary Information
Allergies (if none write none in allergy 1)
Allergy 1
Allergic reaction 1
Medication required 1
Allergy 2
Allergic reaction 2
Medication required 2
Allergy 3
Allergic reaction 3
Medication required 3
Other allergic reactions, medication or information


5. Medication (prescribed and non prescribed)
Medication 1
Medication 1 is taken for
Medications 1 dosage
Medication 1 start date
Medication 1 known side effects
Medication 2
Medication 2 is taken for
Medications 2 dosage
Medication 2 start date
Medication 2 known side effects
Medication 3
Medication 3 is taken for
Medication 3 dosage
Medication 3 start date
Medication 3 known side effects
Other Medications, taken for, dosage and side effect information

6. Medical history current and past (please select yes or no)*
	YES	NO
I have had a seizure within the last 2 years
Hospitalisation / emergency room / urgent can in the past 2 years
History of heart attack, bypass, rhythm abnormality
Medical device (hearing aid / prosthetic device)
Orthopedic problem, neck, back, ankle or knee
Currently pregnant
Asthma
Diabetic requiring medication
Organ (s) removed - is yes please indicate which one (s)

7. Heart Risk Assessment*
	YES	NO
Diagnosed high blood pressure, even if controlled
Smoker
Abnormally high cholesterol level
Family history of heart attack, bypass, sudden unexplained death before 60
Unexplained chest pain, shortness of breath, heart palpitations, sweats
Fainting spells, dizziness

8. Activity Log Any of our trips involving hiking, mountain biking or other strenuous activity requires that participants be reasonably fit. Please indicate below regularly performed exercise activities. For safari only trips it is not necessary to fill out this section.
Activity	Frequency / time / distance / intensity





9. Arrival & departure details
Arrival in East Africa
Date of arrival in East Africa	*
Port / airport of arrival	*
Airline & flight number	*
Time of arrival	*
Departure from East Africa
Date of departure from East Africa
Port / airport of departure
Airline & flight number
Time of departure

10. Preferences & special interests Where ever possible we will always try to cater for specific preferences or interest such as bird watching, animal behaviour or cultural interests. Please let us know any additional information below.
Drinks preference
Other preferences
Additional information

	YES	NO
I have read Summits Africa Terms and conditions


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info@summits-africa.com

emergency contact: +255 (0) 784 522090

Summits Africa is a fully registered and licenced Tanzanian company