Register For Your Upcoming Trip:   Please submit ONE PER PERSON Name: Last: (As on your passport) My contact information is the same as: (If your contact information is the same as a traveler who has already completed this form you may skip to the "Personal Profile" section) Address: Address 2: City, State/Territory: --Any State-- Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces America Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Labrador Louisiana Maine Manitoba Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Marianas Northwest Territories Nova Scotia Nuevo Leon Ohio Oklahoma Ontario Oregon Pacific Islands Palau Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Postal Code: Country: Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador England Equatorial Guinea Eritrea Espana Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and Mc Donald Islands Honduras Hong Kong Hungary Iceland India Indonesia Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent Samoa San Marino Sao Tome and Principe Saudi Arabia Scotland Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka St. Helena St. Pierre and Miquelon Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay USA Uzbekistan Vanuatu Vatican City State Venezuela Viet Nam Virgin Islands Wales Wallis and Futuna Islands Western Sahara Yemen Zambia Zimbabwe Email: Phone:   Work: Cell:   Fax: Trip and Dates with H2O Patagonia: Emergency Contact Information: Name of Emergency Contact #1:   Phone: Address:   City: State/ Province:   Postal Code: Email: Name of Emergency Contact #2:   Phone: Address:   City: State/ Province:   Postal Code: Email: Flight Information: Incoming Airline and Flight Number: City and Date of Departure: City of Arrival: Date/Time of Arrival: I am flying through:  Chile  Argentina Outbound Airline and Flight Number: City of Departure: Outbound Departure Date: Time of Departure: Personal Profile: Your Age (at time of trip): Weight:  Height:  Passport number: Nationality: Date of Birth:      Athletic Background: Rafting Experience: Horeseback Riding Experience: Allergies: Dietary Restrictions: Current Medications: Medical Conditions: Additional Comments: Photo Release: I irrevocably grant to H2O Patagonia the right to distribute, transmit, publish, copy, or otherwise exploit, either in whole or in part, either digitally or in any other medium now known or later discovered, the photographs and/or video footage taken during my commercial trip with H2O Patagonia. I understand and agree that the images may be used and exploited without identifying me as their subject. I release and discharge H2O Patagonia and its agents, representatives, and assignees from any claim or cause of action, now known or later discovered, for, among other things, invasion of privacy, right of publicity, and defamation arising out of the use and exploitation of the images. I represent and warrant that I am over the age of eighteen years. I acknowledge that I have read H2O Patagonia's Photo release policy noted above and I agree. I do not agree. H2O Patagonia Acknowledgement of Risk and Release of Liability: I acknowledge that H2O Patagonia has recommended that I purchase travel insurance. I am aware that I can choose to participate in a variety of adventure activities, including Class IV-V whitewater rafting, horseback riding, Class II-III kayaking, canyoning, and trekking in a wilderness setting. I am aware that should I choose to do any of the above activities, I am assuming responsibility for all of the risks inherently involved. I understand that whitewater and wilderness environments are unpredictable, and that uncertainty is inherent in these activities. The risks in whitewater sports, horseback riding, canyoning, and trekking include but are not limited to: Slipping on wet surfaces and falling against or being thrown against hard objects in the raft, river, on the bank or in or along a tributary or canyon walls. Being struck by, or falling against, a rock or sharp object while climbing or hiking or horseback riding. Exposure to high elevation and extreme weather, including thunderstorms with hail and lightning, and intense sunlight. Infection from food, water or airborne bacteria or viruses. Prolonged delay in ability to obtain medical care in a medical facility. Drowning or prolonged exposure to cold water. Natural disasters such as flash floods, wind storms, rock falls etc. Injury or death due to aircraft or vehicle accident while en route to and from the river. Injury or death while riding on or in the presence of domestic animals. Injuries resulting from falling from a raft, canoe, kayak or other boat into rapidly flowing water capable of sweeping the strongest swimmer into or through the hazards common to riverbeds such as rushing current, rocks and boulders, waves and hydraulic systems which can entrap a boat or swimmer. I understand that the combination of moving water and natural conditions may cause unpredictable consequences which may add to or compound these risks. I further understand that life jackets and availability of rescue equipment are no guarantee that the risks inherent in whitewater sports and the wilderness and river environments can be successfully avoided and, many times, may prove ineffective in reducing or eliminating a particular risk. I also understand that even the most highly trained, competent and experienced guide may misjudge the circumstances of river and/or wilderness conditions, the result of which could be increased risk of injury or death. I understand that even the best equipment may sometimes fail, and that this failure may also result in increased risk of injury or death. By signing below, I acknowledge that I have read this disclosure of the risks which I hereby agree to assume upon engaging in whitewater sports, horseback riding, canyoning, and/or trekking. I acknowledge that I understand the risks, and agree to abide by all instructions and warnings of the expedition leader (verbal and written.) I for myself, my personal representatives, my heirs and successors, and executors hereby release and hold harmless H2O Patagonia and its agents, employees, associates, successors, and assignees from any liability actions, causes of action, and demands of every kind or nature which I have or which may arise out of or in connection with my participation in any adventure activities undertaken in the wilderness or river environment. I hereby release and discharge the above individuals from liability for any harm or injury sustained by me as a result of my participation in whitewater sports, canyoning, horseback riding and/or trekking. I further agree that in consideration of the above named individuals' permitting the minor(s) on whose behalf I have executed the Acknowledgement of Risk and Release of Liability to participate in whitewater sports and/or horseback riding, canyoning, and trekking, I shall indemnify and hold those individuals harmless for any claims which are brought by or on behalf of such minor(s) and which are in any way connected with such minor's participation in those sports and related activities. I specifically represent that I have authority to execute this Release of Liability on behalf of such minor(s) and I understand that this representation will be relied upon by the stated above named individuals in permitting such minor to participate in stated activities. I acknowledge that I have read and agree to H2O Patagonia's Risk and Release of Liability I do not agree.