Name
*
First Name
Last Name
Tour/expedition dates
*
PTOR'S BACKYARD (La Grave) Expedition: January 18-26
KYRGYZSTAN Self/Privately-Guided WK1: January 19-25
KYRGYZSTAN Guided WK1: January 26-February 1
KYRGYZSTAN Guided WK2: February 2-8
KYRGYZSTAN Guided WK3: February 9-15
KYRGYZSTAN Guided WK4: February 16-22
KYRGYZSTAN Guided WK5: February 23-March 1
KYRGYZSTAN Guided WK6: March 2-8
KYRGYZSTAN Self/Privately-Guided WK2: March 9-15
SVANETI Expedition: February 11-21
RACHA Expedition: February 21-March 2
SPANISH PYRENEES Expedition: TBA
MYSTERY TRIP Expedition: March 2-10
LOFOTEN Expedition: March 29-April 5
SVALBARD Expedition - Session One: April 20-28
SVALBARD Expedition - Session Two: April 27-May 5
GREENLAND Expedition - Session One: April 25-May 3
GREENLAND Expedition - Session Two: May 2-8
CHILE Expedition - Volcanoes Itinerary: TBA September-October
CHILE Expedition - Mystery Itinerary: TBA October
Gender
*
Male
Female
Nonbinary
Prefer not to say
Date of birth
*
MM
DD
YYYY
Have you had any serious illnesses or major accidents in the past 2 years?
*
No
Yes
If yes, please describe:
Do you have any physical limitations or medical conditions that might restrict your full participation in the tour/expedition?
*
No
Yes
If yes, please describe:
Do you have any known allergies to food, medications or other?
*
No
Yes
If yes, please describe (severity, reactions, etc):
Aside from allergies, do you have any specific dietary needs or concerns?
*
No
Yes
If yes, please describe:
Please describe your physical activity during a normal week (activity type, frequency, duration, etc):
*
Do you have recurrent or chronic issues with any of the following?
*
If you answered yes to any of the above, please describe (frequency, date diagnosed, symptoms experienced, etc):
Do you get cold easily?
*
No
Yes
If yes, please describe:
Do you use tobacco?
*
No
Yes
If yes, please provide details (how much/how often)
Are you taking any medications?
*
No
Yes
If yes, for what? Schedule and dosage?
Are you pregnant?
*
n/a
No
Yes
If yes, when is your expected due date?
MM
DD
YYYY
Do you have any other conditions that might affect your physical or mental health?
*
No
Yes
If yes, please describe:
Emergency contact name
*
First Name
Last Name
Emergency contact relationship
*
2nd Emergency contact name (optional)
First Name
Last Name
2nd Emergency contact relationship (optional)
The information I have provided above is true, complete and correct (please check box).
*
Electronic signature (type name)
*
Date
*
MM
DD
YYYY
