Please fill out this form completely. All basic information is required.
Name:*
Address:*
Phone Number:*
Email:*
Arrival and Departure Dates:
Which Lodges do you plan to visit?
Do you have any dietary restrictions or requests?
What beverages do you prefer? Please check all that apply: BeerRed WineWhite WineWhiskeyGinRumVodkaScotchCokeSpriteDietWaterRegular/herbal Tea
Are there any medical/physical conditions we should be aware of? Please explain in detail:
Person(s) to contact in case of emergency: Name Phone Email
Name Phone Email
Please indicate if you need to rent fishing of hunting gear.
Rod and Reel: YesNo
Waders: YesNo
For waders, please give us your measurements: Waist Height Weight Shoe Size
IMPORTANT! Your Flight Information: Please forward us your international and domestic flight confirmations that were/will be emailed to you via the airlines or agent. Please forward to jcampa@flyfishingpatagonia.com
Passport information for all guests: Guest 1 Name on Passport: Passport number: Issue Date: Expiration Date: Nationality: Date of Birth:
Guest 2 Name on Passport: Passport number: Issue Date: Expiration Date: Nationality: Date of Birth:
Guest 3 Name on Passport: Passport number: Issue Date: Expiration Date: Nationality: Date of Birth:
Guest 4 Name on Passport: Passport number: Issue Date: Expiration Date: Nationality: Date of Birth:
Guest 5 Name on Passport: Passport number: Issue Date: Expiration Date: Nationality: Date of Birth:
Guest 6 Name on Passport: Passport number: Issue Date: Expiration Date: Nationality: Date of Birth:
Guest 7 Name on Passport: Passport number: Issue Date: Expiration Date: Nationality: Date of Birth:
Guest 8 Name on Passport: Passport number: Issue Date: Expiration Date: Nationality: Date of Birth:
Special interests or additional comments to help us insure your comfort and satisfaction:
How did you hear about us? Referred by whom?
