Details in this form must be the same as appears in your passport. Please complete one form for each individual

Emergency contact details :

Emergency contact #1

Emergency contact #2

Trek details

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.

Personal Information Form

Emergency contact details :

Emergency contact #1

Emergency contact #2

Trek details

T-Shirt size

Health questionnaire

Have you ever had an asthma attack that required medical assistance over the last 12 months?

Have you ever had a heart attack or stroke ?

Do you have diabetes and have you had issues controlling your blood sugar within the last 3 months?

Have you ever experienced unexplained pains in your chest at rest or during physical activity?

Have you any joint or other similar conditions where you may have been told it could worsen with physical activity?

Is there any family history of heart disease?

Are you a smoker?

Please describe your current physical activity and exercise level :

Do you have high cholesterol?

Do you have high blood pressure?

Do you have high blood sugar?

Are you pregnant or have you given birth in the last 12 months ?

Have you spent time in hospital (including day admission) for any medical condition within the last 12 months?

Are you currently taking any prescribed medication?

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