International Adventures Booking Form

INTERNATIONAL ADVENTURES BOOKING FORM, MEDICAL HISTORY AND LIABILITY WAIVER

INTERNATIONAL ADVENTURES BOOKING FORM

Full Name *

Age and Date of Birth *

Email *

Phone *

Home Address - include suburb, state and postcode and country. *

Which International Adventure would you like to join? *

Dates of Adventure *

DO YOU HAVE ANY PREVIOUS TREKKING OR MOUNTAINEERING EXPERIENCE? IF YES, PLEASE PROVIDE DETAILS: *

HAVE YOU EVER BEEN ABOVE 4000 METRES ALTITUDE BEFORE? IF YES, PLEASE PROVIDE DETAILS AND THE YEARS IN WHICH YOU ACHIEVED THOSE ALTITUDES *

WHAT ARE YOUR GOALS FOR PARTICIPATING IN THIS ADVENTURE?? *

Name/s and contact details of person/s to be contacted in the event of an accident or other emergency. *

To be completed if participant is under 18. Parents'/Guardians' full names.

BOOKING CONDITIONS. See link at the bottom of this page. *

IN CHECKING THIS BOX, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND ACCEPT THE BOOKING CONDITIONS OF CONTRACT ACCOMPANYING THIS BOOKING AND THE OBLIGATIONS SET OUT IN THE CONDITIONS, PARTICULARLY THOSE RELATING TO THE RELEASE AND WAIVER OF LIABILITY. IF AGED UNDER 18, THIS FORM REQUIRES THE SIGNATURE OF YOUR PARENT OR LEGAL GUARDIAN.

CONFIDENTIAL MEDICAL HISTORY. The following information is intended to assist K7 Kosciuszko Adventures in case of any emergency with you / your child / person in your legal care. *

I am aware that K7 Kosciuszko Adventures activities / programs, in addition to usual dangers and inherent risks, has certain additional dangers and risks which may include: • physical exertion for which I may not be prepared • weather extremes subject to sudden and unexpected change • remoteness from normal medical services • evacuation difficulties if I am disabled or travelling on country roads. I accept that K7 Kosciuszko Adventures staff/instructors/leaders will have the ultimate say in whether or not I or any person in my care is able to participate in an adventure activity or program, or if they feel that a person or the group is at risk, they have the right to make alternative arrangements. In order to ensure safe participation in the activities / program, or if I have any doubts about the suitability of my health or the health of people in my care, I can always consult my Doctor for advice or approval. On extended programs, participants may be required to produce a Doctorʼs certificate. This must be produced before the day of departure.

Learning difficulties need to be discussed so that Leaders are able to accommodate accordingly. Please describe any Learning Concerns if applicable *

Do you (or your child or person in your legal care on this adventure) suffer from any of the following? Any pre-existing medical or other condition that may affect or risk other persons or yourself. Please list any of the following - Asthma, Diabetes, Epilepsy/Fits, Fainting/Dizziness, Blackouts/Migraines, Disability, Heart/Blood Condition, Allergic Reactions, Pregnancy, Uneven Pupils, Recent Injuries, Medications, Other ... *

Please list any allergies you suffer and their symptoms. Please identify the appropriate medication that you will carry if necessary to do so. *

Tetanus Immunisation. Tetanus is normally given at five years of age as a Triple antigen or CDT and at fifteen years of age as ADT. Year of last tetanus immunisation. *

Medication. Is it necessary for you or your child or person in your legal care to carry their own medications? Please provide Name of Drug, Dosage and Frequency *

Consent for Medical Attention *

I authorize the instructor in charge to administer first aid and call an ambulance if necessary for the medical attention of myself or my child or person in my legal care. I agree to bear any cost thereby incurred.

LIABILITY WAIVER. See link at the base of this page. *

In checking this box, I acknowledge that I have read, understood and accept the conditions of the Liability Waiver

Date *

USE THIS LINK TO READ THE BOOKING CONDITIONS

Use this link to read the INTERNATIONAL ADVENTURES LIABILITY WAIVER

INTERNATIONAL ADVENTURES BOOKING FORM, MEDICAL HISTORY AND LIABILITY WAIVER

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