Name
*
First Name
Last Name
Tour/expedition dates
*
CHILE Expedition - Volcanoes Itinerary: September 22-October 1
CHILE Expedition - Mystery Itinerary: October 5-14
PTOR'S BACKYARD (La Grave) Expedition: TBA January
KYRGYZSTAN Guided WK1: January 25-31
KYRGYZSTAN Guided WK2: February 1-7
KYRGYZSTAN Guided WK3: February 8-14
KYRGYZSTAN Guided WK4: February 15-21
KYRGYZSTAN Guided WK5: February 22-28
KYRGYZSTAN Guided WK6 (SPLITFEST): March 1-7
SVANETI Expedition: TBA February
RACHA Expedition: February 27-March 8
LOFOTEN Expedition: March 28-April 4
SVALBARD Expedition - Session One: TBA April
SVALBARD Expedition - Session Two: TBA April
GREENLAND Expedition - Session One: April 24-May 2
GREENLAND Expedition - Session Two: May 1-9
MYSTERY TRIP Expedition: TBA
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
