Playful Coconuts Travel Booking Form

First Name*

Last Name*

Primary Email*

Address Line 1*

Address Line 2

City*

State / Province*

ZIP / Postal Code*

Primary Phone*

Gender

Name as it appears on your Passport

Passport Number

Passport Issuing Country

Passport Issue Date

Passport Expiry Date

Date of Birth*

Country of Birth

Upload a photo (JPG format) of your passport information page.

Medical Information (medication, allergies, etc.).

Provide any information that may be required in an emergency.

If you would like an insurance quote - do you want cancellation, out-of-province medical or both?

Cabin/Stateroom type? (Single, Double or other)

Enter the name of the person you will be sharing a cabin with. NOTE: They will need to fill out a separate booking form.

Do you require accommodations for accessibility reasons? (i.e. no stairs). Provide details of the required accommodations.

Name on Credit Card

Credit Card type (Visa, MC, AMEX only)

Credit Card Number

Credit Card Expiry Date

CVV

Emergency Contact Name*

Emergency Contact Relationship (sister, husband, son, friend, etc.)

Emergency Contact Phone

Emergency Contact Email

Playful Coconuts is an NorthStar Travel affiliate, 678 Belmont Ave W Unit 201, Belmont Village, Kitchener, Ontario TICO # 2569684