Name *
Email Address *
Your Tour *
Tour Dates *
Date of Birth *
dd/mm/yyyy
Gender *
Male Female
Prinicipal Health Care Plan *
Prinicipal Health Care Plan # *
Extended Insurance
Extended Insurance #
Your Doctor's Name *
Doctor's Phone Number *
Emergency Contact *
Emergency Contact Phone *
Emergency Contact Relation
Allergies *
Please list any allergies, including food allergies (not preferences), bug bites, medications etc. Put none if no allergies.
Medications *
Please list any medications you are taking, including prescription, non-prescription and nutritional supplements.
Last Tetanus Immunization
Your Health *
Please describe your overall health as well as you can.
Chronic Conditions *
Do you see a Doctor regularly for any chronic conditions? If yes, please explain.
Past Surgeries, Injuries, Hospitalizations *
Please list any past surgeries, significant injuries and hospitalizations.
If Female, Are You Pregnant?
Yes No
Please Check All That Apply
Please describe below.
Cardiac Disease Diabetes Stroke Seizures High Blood Pressure Gastro-Intestinal Disease Lung Disease Kidney Problems Liver Problems Cancer Thyroid Problems Migraines Musculoskeletal Problems Abnormal Bleeding, Blood Problems Mental Health Disorders
Please Describe Any Above Conditions *
Have You Ever Experienced Cardiac Arrest or Heart Attack
Yes No
Please Rate Your Fitness *
This section requires you to read our Hiking Experience & Fitness Levels Section to determine your level of physical fitness and technical skill level.
Please refer to our rating system before entering the below questionnaire. It is very important for us to have an understanding of your hiking experience and your fitness levels.
—Please choose an option— 1 (Not active) 2 (I am working on getting into shape) 3 (I am relatively in good shape) 4 (I am in great shape) 5 (I am a super fit machine)
Hiking Experience *
—Please choose an option— 1 (Newbie) 2 (Beginner) 3 (Intermediate) 4 (Strong Intermediate) 5 (Advanced)
Please Rate Your Swimming Ability
—Please choose an option— Help! Doggy Paddler Strong swimmer
Physical Limitations *
Would you or you Doctor say you have any significant physical limitations?
Anything Else That May Help Us?
Feel free to tell us anything else you feel might help.
Diet
Please describe any dietary restrictions. We will do our best to suit your needs. Feel free to include your favourite kind of foods.
Tell Us A Bit About Your Hiking Experience
Please describe how long you have been hiking for, the trails you are used to hiking, any destinations in the world you have hiking in.
I have Read The Hiking & Fitness Rating For This Ride