Name
*
First Name
Last Name
Tour/expedition dates
*
CHILE Expedition - Itinerary One: Volcanoes - September 22-October 1
CHILE Expedition - Itinerary Two: Mystery - October 3-12
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 2-10
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?
*
High blood pressure
Heart disease
Arrhythmia
Blood clots
Bleeding disorders
Asthma
Respiratory infection
Diabetes
Headaches/migraines
Epilepsy
Bladder/kidney infection
Digestive issues
Eating disorder
Dislocations
Shoulder, back or knee problems
Frostbite
Previous altitude problems
Speech, vision or hearing impairment
NONE OF THE ABOVE
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