Client Profile Form

Name*

Title First Last

Nickname/Common Name

Gender

Male

Female

Other

Birthdate

Month

Day

Year

Phone

Phone*

Email*

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Use Alternate Address

Alternate Address

Street Address City State / Province / Region ZIP / Postal Code Country

Emergency Contact #1

First Last

Relationship

Location

Phone

Emergency Contact #2

First Last

Relationship

Location

Phone

Nationality

Passport #

Issuing Country

Location of Issue

Date of Issue

Month

Day

Year

Date of Expiry

Month

Day

Year

Please upload a copy of the photo page of each passport

Drop files here or

Accepted file types: jpg, jpeg, gif, png, tiff, pdf, Max. file size: 50 MB.

Nexus #

Redress #

Known Traveller #

Please describe any allergies or dietary requirements you have

Rate Your Fitness Level

Check the box that best represents your fitness level.

Very Fit

Somewhat Fit

Moderate Fitness

Low Fitness

Do you have any spinal injuries or back issues?

Yes

If yes, please describe any concerns we should be aware of

There may be instances where the terrain will be uneven and/or there are stairs. Do you foresee any issues navigating this?

Yes

If yes, please describe any concerns we should be aware of

Please describe any other health or mobility issues we should be aware of.

Due to the remoteness of the location you will be traveling to, you will be required to have Travel Insurance that includes Medical Insurance and Emergency Evacuation Coverage. Momenti Travel can assist you with securing your travel insurance. Additionally, vaccinations and entry requirements vary country by country. Your Final Confirmation details will include the requirements for the destinations you will be visiting.

Alcoholic Beverage Preferences
If you do not drink alcoholic beverages, please skip this section.

Wine Preferences

Cocktail Preferences

Beer Preferences

Occasion(s) you are Celebrating

check-off any that apply

Birthday

Anniversary

Honeymoon

Other

If other, please describe

Any special requests?

Airline Preferences

Preferred Airlines

Preferred Class of Service

Airline Seating Preference (Window/Aisle)

Meal Preference

Guest Room Preference

Bed Type Preference

King

Queen

Twin

No Preference

Floor Preference

High Floor

Low Floor

No Preference

Views

Best View Available

Partial View

No Preference

Bedroom Type

Guest Room

Adjoining Rooms

Junior Suite

One Bedroom Suite

Two Bedroom Suite

Other

If other, please describe

Loyalty Programs

Please use the plus (+) sign to add additional programs.

Type (Hotel, Air, Car, Other)

Name of Program

Membership Number

Phone

This field is for validation purposes and should be left unchanged.

Client Profile Form

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