Alpine Recreation - Climbing Application Form

Trip details

Please enrol me for:			Start date:		Check dates: Introductory/Intermediate Climbing
Please specify if necessary:

Contact details

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

Emergency contact details

Name:

Relationship:

Phone:

Address:

Personal details

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

Medical details

Please provide the following information about your health and fitness which may affect the adventure you are going to undertake. Check 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 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?

Dietary Requirements

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

Drinks preference for Advanced Climbing & Guided Ascents (choose up to 3):

coffee (filter)

coffee (instant)

hot chocolate

raro/tang

tea (black)

tea (herbal/fruit)

Experience & Fitness

Please provide the following information about your outdoor experience and fitness. Check the appropriate answer and answer all questions.

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?

Additional Information Introductory Climbing

Do you have any rock climbing experience?				YES NO
If so, up to what grade?

Additional Information Intermediate & Advanced Climbing

Please give full details of your previous climbing experience and current fitness training. For Mount Cook and Mount Tasman please give a list of previous ascents.

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.