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 20-28
KYRGYZSTAN Self/Privately-Guided WK1: January 21-27
KYRGYZSTAN Guided WK1: January 28-February 3
KYRGYZSTAN Guided WK2: February 4-10
KYRGYZSTAN Guided WK3: February 11-17
KYRGYZSTAN Guided WK4: February 18-24
KYRGYZSTAN Guided WK5: February 25-March 2
KYRGYZSTAN Guided WK6: March 3-9
KYRGYZSTAN Self/Privately-Guided WK2: March 10-16
SVANETI Expedition: February 6-16
RACHA Expedition: February 16-25
SPANISH PYRENEES Expedition: February 25-March 4
MYSTERY TRIP Expedition: March 31-April 7
SVALBARD Expedition - Itinerary One: April 7-15
SVALBARD Expedition - Itinerary Two: April 28-May 8
GREENLAND Expedition - Session One: April 26-May 4
GREENLAND Expedition - Session Two: May 3-11
Gender
*
Male
Female
Nonbinary
Date of birth
*
MM
DD
YYYY
Are you fully vaccinated for COVID-19?
*
Yes
No
Do you have documentation proving full vaccination?
*
Yes
No
n/a
Have you been infected with COVID-19?
*
Yes
No
Have you had any other 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
