Client Info Form Trip InformationTrip Name*Start Date* End Date Number of People in Group with NamesClient InformationGender*MaleFemaleName* First Last Date of Birth* Email* Height (applicable for bike rentals)*If you are filling out one form for a group, please let us know all heights.Country of ResidenceMedical Conditions or Allergies*If you are in a group and are filling out one form for the group. Please detail the names for Allergies or Medical Conditions of each one of you.Dietary Needs/ Type of Food Requested*If you are in a group and are filling out one form for the group. Please detail the names for Dietary Needs or restrictions you have of each one of you.Other Special Needs or Important NotesRoom and Bed PreferencesPassport InformationPhonePassport No.Passport Expiration Date NationalityEmergency Contact InformationEmergency Contact*Phone*phone where we can reach your emergency contactRelationDetailsInternational insurance InformationInsurance CompanyPolicy NumberContact Phone #Worldwide Assistance #Flight InformationArrival Date Arrival TimeArrival Flight #Departure Date Departure TimeDeparture Flight #Liability WaverRELEASE OF LIABILITY WAIVER *This release of liability must be signed, dated and given to Old Town Outfitters staff before departure* In consideration of being permitted to participate in mountain biking, rock climbing, hiking, kayaking, caving or related activities under the auspices of Old Town Outfitters, I, the undersigned, hereafter, understand, acknowledge and agree that: 1. RISK OF BODILY INJURY OR DEATH: Participation in sports such as Mountain Biking, Hiking, Rock Climbing, Sea Kayaking, Volcano Climbing and other outdoor activities associated with Old Town Outfitters may expose me to serious bodily injury or death. I may be exposed to these risks in many ways including but not limited to the following: transit to and from activities, riding bicycles on or off road, in traffic, taking a fall, getting in or out of boats, crossing creeks, or at any time around water. Exposure to environmental elements including -but not limited- to the following: sun, wind, rain, lightning, insects, plants or animals may also cause bodily injury and or death. 2. NEGLIGENCE: Injuries may occur as a result of my negligence, the negligence of others, or through no fault of myself or anyone else. I, the participant, having voluntarily chosen to participate assume full responsibility for my own actions. I knowingly, freely, and expressly assume all risks, both known and unknown, of bodily injury or death or damage or loss of personal property, as a result of my own negligence or the negligence of others. I further acknowledge that injury or death could result from the negligence of other group participants or guides and agree to hold harmless Old Town Outfitters and its staff for any act of negligence by other participants or the negligence of those persons released from liability below. 3. MEDICAL CARE: Any of the before listed activities may take participants to remote areas where professional medical care may not be readily accessible. Old Town Outfitters will use its best efforts to get injured participant(s) medical attention. Participants are responsible to reimburse Old Town Outfitters for all costs associated with any medical attention or assistance. 4. REIMBURSEMENT FOR DAMAGED GEAR: I assume complete responsibility under any circumstances, for all damages to any bicycles or gear issued to me on trip, or rented from Old Town Outfitters. I am responsible to compensate Old Town Outfitters the replacement value for any damages incurred to bicycles or other gear while on trip or renting from Old Town Outfitters. 5. WAIVER OF LIABILITY AND ASSUMPTION OF RISK: I certify that I have had adequate time to read, review, and understand paragraphs 1-4 and thus I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY AND HOLD HARMLESS the Old Town Outfitters company, the owners, lessors and lessees of premises used to conduct the outdoor activities, their officers, officials, instructors, guides, volunteers, equipment suppliers, agents and/or employees (“the Releasees”), with respect to any and all injury, disability, death, or loss or damage to personal property, whether caused by the negligence of the releases, theft or otherwise; and I understand that, if I elect not to sign this, I will receive a refund of the trip fee. * I have read and accept the Liability Waver Payment and Refund PolicyPayment Terms & Methods Thanks for reserving a trip with Old Town Outfitters! We are excited to see you soon here in beautiful Guatemala! In order to confirm your trip, Old Town needs to receive a deposit based on your quoted trip price: • If your trip start date is MORE than 15 days away – an initial deposit of 50% of your quoted trip price is necessary to confirm your trip booking. • If your trip start date is LESS than 15 days away – FULL PAYMENT of your quoted trip price is necessary to confirm your trip booking. This payment can be easily made in few different ways. Please read below to determine the method which works best for you. Please be aware that different payment methods incur different fees. BANK OPTIONS 1. You can make a bank deposit to the following account: Citibank NY 111, World Trade St., N.Y. 10043 ABA 021000089 or SWIFT CITIUS33 TO BE DEPOSITED TO ACCOUNT: 36236584 I/N/O BANCO REFORMADOR, S.A. – GUATEMALA For Further Credit Account # 4761000494 I/N/O Matthew Ryan Hartell 2. You can make a direct bank transfer from your own bank account to ours. (Keep in mind that there will be a fixed charge by your bank for this service, which depends entirely on the relationship between the two banks. Please consult your bank to for more information about the charge, as you will need to add that amount to your total transfer) CREDIT CARD OPTIONS You can use any major credit card to make your deposit. Our office can send you an e-mail invoice via PAYPAL with the appropriate request. PAYPAL is a secure credit card payment service that accepts most major credit cards, and is simple to use. If you pay your deposit to us through the PAYPAL service, please be aware that there is a 3% surcharge that will be added to the invoice as a service fee. 5a. Avenida Sur #12, Antigua, Guatemala Tel: +502.5399.0440 Fax: +502.7832.4171 email@example.comTrip Cancellation & Refund Policies Trip Cancellation Policy If - for any unfortunate reason – it is necessary to cancel your trip with Old Town Outfitters, please be aware of our cancellation policy: More than 45 days prior to trip start date: Any cancellation fees, surcharges, or nonrefundable deposits charged to Old Town Outfitters by individual hotels, airlines or other third parties will be charged. The remainder of any deposits paid to Old Town Outfitters will be refunded. 45-30 days prior to trip start date: Any cancellation fees, surcharges, or nonrefundable deposits charged to Old Town Outfitters by individual hotels, airlines or other third parties will be charged. Additionally, a cancellation fee of 10% of the total trip cost will apply. The remainder of any deposits paid to Old Town Outfitters will be refunded. 29 to 15 days prior to trip start date: Any cancellation fees, surcharges, or nonrefundable deposits charged to Old Town Outfitters by individual hotels, airlines or other third parties will be charged. Additionally, a cancellation fee of 25% of the total trip cost will apply. The remainder of any deposits or payments paid to Old Town Outfitters will be refunded. Less than 15 days prior to trip start date: No refunds can be issued for trips cancelled in this time period. All payments made to Old Town will be retained. (0% Refund) General Refund Policy All refunds are made in accordance with our Cancellation Policy outlined above. Additional refunds CANNOT be made for “no-shows”, or any unused part of an itinerary whether voluntary, caused by airline delay or cancellation, or any other factor beyond the control of Old Town Outfitters. This includes - but is not limited to - acts of god (sickness, injury, poor health, weather, etc.) strike, detention, riot, war, quarantine, theft, civil disturbances, government regulations or restrictions, third-party or subcontractor negligence, or any other. No responsibility can be accepted for expenses incurred due to delay or change in schedule or other causes. We strongly recommend that clients purchase comprehensive trip-cancellation insurance through a third party insurer (i.e. Travel Insurance) Note: this insurance IS NOT provided by Old Town Outfitters. 5a. Avenida Sur #12, Antigua, Guatemala Tel: +502.5399.0440 Fax: +502.7832.4171 firstname.lastname@example.org* I have read and understand the Payment and Refund Policy Email Email Email This iframe contains the logic required to handle AJAX powered Gravity Forms.