Trip details

Destination

Activity

Departure Date

YYYY

Flight Details (If known/booked)

Date of Arrival:

Date of Departure:

Personal Details

Name

First Name

Last Name

DOB

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Landline

Mobile

Nationality

Passport No

Height (cm)

Weight (kg)

Clothing Size

Emergency Contacts

Name

First Name

Last Name

Relationship to you

Mobile

Landline

Expedition Experience

To help us understand your experience & comfort levels it is important that you fill in the following section with as much information as possible. If the section is not relevant to your expedition then please leave it blank. If you are concerned regarding the level of ability which is required then please contact Monix Adventures.

Mountaineering

Please list experience relevant to this expedition, such as peaks climbed, notable routes (grades if known) and altitudes visited.

Ski Mountaineering

Ski Mountaineering Please indicate the level of difficultly you can ski on piste, list off piste/ glacier experience and number of days ski touring.

Medical Questionnaire

It is essential for us to know of any such condition for planning purposes. The following questions have been developed to provide information that may be helpful in assisting us in any medical situation involving you. With this in mind you are requested to provide all relevant details at this time and to advise us of any changes in your health/ fitness between now and the Expedition. If you are uncertain of any health matter please consult your own Doctor before booking.

1. Do you or have you ever suffered from the following? If you answer ‘yes’ to any of the questions please provide further details in the text box below.

Epilepsy/fits or blackouts

Yes

Diabetes

Yes

Recurrent ear or sinus problems

Yes

Problems with mobility/lifting/carrying

Yes

Heart/chest or lung problems

Yes

Blood Disorders

Yes

If you have answered Yes to any of the above please provide details

2. Do you have Asthma?

Yes

If so have you :

a) needed hospital treatment for this?

b) needed steroid tablets?

c) both

d) neither

If ticked then please provide more details

Please include inhalers and other medicines used

3. Have you had any operations?

Yes

4. Have you had any serious illnesses requiring hospital admission?

Yes

5. Have you had a head injury with loss of consciousness?

Yes

6. Please list any medicines that you take regularly

7. Please list any allergies you may have

8. Do you have any specific dietary requirements?

Yes

If yes please could you provide further details:

9. Please add any further relevant information that may affect your ability to fully participate in expedition activities

Security of information and use of images

To ensure the safe running of our Expeditions we need to use the information given on this form. We take full responsibility for ensuring that proper security measures are in place to protect this information when it is passed to our overseas subsidiary offices and third party suppliers. Any images taken of you whilst on our Expeditions, and images made available to us by you, may be used by us for marketing purposes.

Declaration

To the best of my knowledge and belief all information provided on this form is correct and I know of no reason(s) why I should not participate in the Expedition and will not be travelling against medical advice. In signing this form I confirm that I have read and understood the Monix Adventures Limited Terms and Conditions and confirm that I am willing to abide by them. I also confirm I have read and understood the payment schedule and agreed to the payment terms of this booking.

I Agree

Thank you for taking the time to complete our application form. If we need any more information then we will be in touch with you shortly.

Monix Adventures - Booking form

Terms & Conditions