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Details in this form must be the same as appears in your passport. Please complete one form for each individual.
Title*
First Name*
Last Name*
Street Address*
Suburb*
Post Code*
Country*
Passport Number*
Passport date of issue (DD/MM/YYYY)*
Passport place of issue*
Passport expiry date (DD/MM/YYYY)*
Telephone Number*
Date Of Birth (DD/MM/YYYY)*
Select Gender* -- Select Gender --MaleFemale
Height*
Weight*
Occupation*
Email Address*
Full Name*
Relationship*
Phone Number*
Trek Name*
Please enter your preferred month and year only (MM/YYYY)*
T-shirt Size SMLXLXXL
Special Dietary Requirements*
Have you ever had an asthma attack that required medical assistance over the last 12 months? YesNo
Have you ever had a heart attack or stroke? YesNo
Do you have diabetes and have you had issues controlling your blood sugar within the last 3 months? YesNo
Have you ever experienced unexplained pains in your chest at rest or during physical activity? YesNo
Have you any joint or other similar conditions where you may have been told it could worsen with physical activity? YesNo
Is there any family history of heart disease? YesNo
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Are you a smoker? YesNo
Please describe your current physical activity and exercise level: Very littleLightModerateVigorous
Do you have high cholesterol? YesNo
Do you have high blood pressure? YesNo
Do you have high blood sugar? YesNo
Are you pregnant or have you given birth in the last 12 months? YesNo
Have you spent time in hospital (including day admission) for any medical condition within the last 12 months? YesNo
Are you currently taking any prescribed medication? YesNo
Note: if you have answered yes to any of the above questions, further information must be obtained from your medical practioner, and detailed on the wild trek medical form, and your doctor must state you are medically fit to undertake the trek.
By checking this button you acknowledge that you have read and understood the Terms & Conditions, and you accept all Terms & Conditions.
We recommend you print a copy for your personal records prior to checking the acceptance button.
