APPLICATION FORM FOR INTRODUCTORY CLIMBING

Please download this form, complete it and return it to Alpine Recreation, P.O.Box 75, Lake Tekapo, New Zealand; or fax to (03)680 6765; or attach it to an e-mail to  climb@alpinerecreation.com . Any information you provide will be treated as strictly confidential

Please enrol me for a Introductory Climbing Course. Date: ………………….…………..

PERSONAL

Given name:..................................   Family name:......................................................

Home address:..........................................…….........................Post Code ………..

Phone (home): ..........................Phone (work): ..................... Fax:……………..…...

E-mail: ……………………......Date of birth: ............ Occupation:............................

EMERGENCY CONTACT

Name:................................................. Relationship: ..................................................

Phone: ............................... Address:……………………………………………….

MEDICAL
Please provide the following information about your health and fitness which may affect the adventure you are going to undertake. Circle the appropriate answer and answer all questions.

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 an Introductory Course? Any recurring sports injury?

Yes/No
 
If you have answered 'Yes' to any part of A) to E) above, would you please elaborate?

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EXPERIENCE & FITNESS
1) Do you have previous tramping / hiking / backpacking / bushwalking experience?  If so, how many years? ………. Yes/No
2) Can you walk 6-8 hours in a day without difficulty? Yes/No
3) Are you able to climb up and down steep slopes with no fear of heights? Yes/No
4) Do you have good balance and are you well-coordinated? Yes/No
5) How do you rate your overall level of fitness? Average/Above average/Very strong
6) Do you have any rock climbing experience?
If so, to what level?.......................................................		 Yes/No

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

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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
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.

Credit Card Details
Please charge my credit card with ...................  for the 50% deposit on the above tour in order to confirm my booking.
Card # .................................................... Expiry Date: .......................
Name: ...................................................... Card type: ..........................
 

SIGNATURE…………………………………………

DATE…………………………………