PERSONAL INFORMATION

FULL NAME: OCCUPATION:

ADDRESS: CITY: STATE: ZIP:

HOME PHONE: WORK PHONE: FAX: E-MAIL:

PASSPORT #: COUNTRY: PLACE AND DATE OF ISSUE:

EMERGENCY CONTACT: PHONE:

FOOD PREFERENCES/DISLIKES?

EXPERIENCE AND TRAINING

PREVIOUS CLIMBING EXPERIENCE:

PREVIOUS TREKKING EXPERIENCE:

GENERAL PHYSICAL CONDITION: AGE: APPROXIMATE WEIGHT/ HEIGHT:

PHYSICAL TRAINING FOR THIS TRIP:

MEDICAL INFORMATION

MEDICAL HISTORY (things we should be aware of i.e. allergies, heart problems, diabetes, mental disorders):

MEDICATIONS:

MEDICAL INSURANCE COMPANY: POLICY #:

We highly recommend a pre-trip physical; let your doctor know you will be doing strenuous exercise at high altitude!

AIRLINE INFORMATION PLEASE FAX OR SEND A COPY OF YOUR ITINERARY!

ARRIVAL AIRLINE: FROM: FLIGHT #: DATE: TIME:

DEPARTURE AIRLINE: FROM: FLIGHT #: DATE: TIME:

ADDITIONAL INFORMATION

PLEASE SEND AN ADDITIONAL BROCHURE TO:

HAVE YOU SENT A DEPOSIT OR FINAL PAYMENT, READ ALL POLICIES, EQUIPMENT LISTS AND PRE-DEPARTURE INFORMATION?

PLEASE COMPLETE QUESTIONNAIRE AND LIABILITY RELEASE, THEN MAIL OR FAX TO:

Adventures International Inc., PO Box 1006, Hood River, OR 97031

800-247-1263 212-918-3409 Fax info@ExploreYourPlanet.com