Enrolment Intermediate / Advanced Climbing

APPLICATION FORM FOR INTERMEDIATE / ADVANCED 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 Climbing Expedition:.............................................................

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 this Climbing Expedition? Or any recurring sports injury?		Yes/No
If you have answered 'Yes' to any part of A) to E) above, would you please elaborate? ........................................................................................................................................................................ ........................................................................................................................................................................
EXPERIENCE & FITNESS Please give full details of your previous climbing experience and current fitness training. For Mt. Cook or Mt. Tasman please give a list of previous ascents. ..................................................................................................................................... ..................................................................................................................................... ..................................................................................................................................... ..................................................................................................................................... NZAC MEMBERSHIP # (if applicable) or membership of overseas Alpine Club? …………
DIETARY REQUIREMENTS Please indicate if you are vegetarian or have any other dietary requirements. …………………………………………………………...............................
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…………………………………