Intergalactic Travel Preparation Checklist
Please complete this checklist to ensure you are fully prepared for your intergalactic journey.
Traveler Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Planned Departure Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Intended Destination Galaxy or Planet
*
Please Select
Andromeda Galaxy
Milky Way - Outer Rim
Triangulum Galaxy
Large Magellanic Cloud
Other
Select the travel gear and supplies you have prepared:
*
Space Suit (Certified)
Oxygen Supply
Universal Translator
Nutrient Packs
Communication Device
Medical Kit
Other
Do you have any dietary restrictions or allergies?
Please rate your readiness for intergalactic travel:
*
1
2
3
4
5
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please indicate any health conditions or special accommodations needed for your travel.
Have you previously participated in intergalactic travel?
*
Yes
No
Additional comments or special requests
Submit Checklist
Should be Empty: