Alpine Recreation - Trekking Application Form

Please note: You can only book online if you provide the secure server with a valid credit card number.

If you wish to pay by cheque please complete, print and sign the application form, and post it with cheque to:
Alpine Recreation, P.O. Box 75, Lake Tekapo, New Zealand.

Any information you provide will be treated as strictly confidential.

Trip details

Please enrol me for:			Start date:		Check dates: Ball Pass/Tekapo Trek
Please specify if necessary:

Contact details

First name:		Last name:
Street / Post Box:	City:	Post Code:	Country:
Phone (home):	Phone (work):	Fax:	Email:

Emergency contact details

Name:

Relationship:

Phone:

Address:

Personal details

Date of birth:			Occupation:
Gender:			Height (cm):			Weight (kg):

Dietary Requirements

Please indicate if you are vegetarian or have any other dietary requirements.

Additional Information FitzGerald Pass Crossing

Do you have previous cramponing experience?

YES NO

Cancellation

I accept the booking conditions and acknowledge that Alpine Recreation cannot refund any trip fees if a trip has to be cancelled after commencement due to unforeseen and uncontrollable circumstances (inclement weather, bad road conditions etc.). If I choose to cancel a trip, I will pay the appropriate cancellation fee as set out in the Company's Booking Conditions.

Equipment

I agree that if I damage the Company's equipment beyond normal wear and tear or lose their gear on a trip, I will be liable for replacement or repair costs as the directors of the Company decide.

Payment

In order to secure a booking a 50% deposit of the tour price is required. The balance is due four weeks before departure date.

Check prices: Ball Pass, FitzGerald Pass, Tekapo Trek.

	I am sending a cheque for the amount of
	I will send a cheque for the balance four weeks before departure
	Please charge my credit card for the amount of
	Please charge my credit card for the balance four weeks before departure

Clicking "Submit" will send your completed booking form to us at our secure server at 2day.com, where you will be asked to provide credit card details (which are necessary to confirm your booking), unless you have chosen the payment-by-cheque option on the form.

Please contact us by phone or fax if you do not receive confirmation within 3 days of booking.

A) Do you/have you suffered from:	- a heart condition?	YES NO
	- high blood pressure?	YES NO
	- epilepsy?	YES NO
	- a bronchial disorder?	YES NO
	- asthma?	YES NO
	- diabetes?	YES NO

B) In the last five years, have you:	- suffered any severe injury?	YES NO
	- undergone any surgical operation?	YES NO

C) Do you have any known allergies?		YES NO

D) Are you taking any medication?		YES NO

E) Do you suffer from any other medical condition(s) which might affect your ability to participate in this trip? Eg. Any recurring sports injury?		YES NO

If you have answered "Yes" to any part of A) to E) above, would you please elaborate?

A) Do you have any previous tramping/hiking/backpacking/bushwalking experience?				YES NO
List the 2 hardest overnight hikes you have done in the last 5 years:
B) Can you walk 6-8 hours in a day without difficulty?				YES NO
C) Are you able to climb up and down steep slopes with no fear of heights?				YES NO
D) Can you clamber up and around big rocks where you may need to use both hands?				YES NO
E) Do you have good balance and are you well-coordinated?				YES NO
F) How do you rate your fitness?