Eco-Tourism Medical Information Declaration Form
Personal Information
Full Name
Date of Birth
Passport/ID Number
Contact Number
Address
Emergency Contact
Name
Phone
Relationship
Medical Information
List any medical conditions
Allergies (including food, medicine, etc.)
Medications currently taken
Do you have any dietary restrictions?
Yes
No
If yes, please specify
Other information or needs we should be aware of
Declaration
I declare that the information provided is true and complete to the best of my knowledge.