Participant Details: EXPEDITION

Participant Details: EXPEDITION
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

Street Address Line 3County

Postcode
E-mail*
Phone Number
Mobile Number*
Date of Birth*

DayMonthYear
MaleFemale
Passport Number*
Passport Expiry*
Nationality*
EXPEDITION
Expedition booked*
Expedition Start date*

DayMonthYear
EMERGENCY CONTACT (NEXT OF KIN)
Name*
Relationship to Participant*
Email*
Phone Number*
TRAVEL INSURANCE

Must cover the relevant altitude, helicopter evacuation and repatriation. Please send a copy of the policy page to info@summitguides.com
Insurance Company*
Policy Number*
Email*
Phone Number*
MEDICAL

NOTE: Disclosure is unlikely to prevent participation and greatly enhances our ability to deliver your Expedition successfully. Any information will be treated confidentially..
Blood Group (if known)
Allergies*

YesNo
If Yes do you carry an EpiPen/Adrenaline? (it is recommended to carry a spare)

YesNo
Diabetes*

YesNo
If Yes, please specify which type and prescribed treatment
Breathing or lung conditions (including asthma)*

YesNo
Cardiac Conditions (eg Chest Pains, Palpitations etc)*

YesNo
Previous Surgery*

YesNo
Musculoskeletal Problems (eg back pain, fractures or dislocations)*

YesNo
Smoker*

YesNo
Alcohol intake per week*

Up to (and including) 14 units per weekMore than 14 units per week
Previous Altitude Illness*

YesNo
Do you take Diamox at altitude?*

YesNo
Do you snore? (If Yes a Single Person Supplement is advised, where available)*

YesNo
If you answered Yes to any of the above, or have any relevant medical conditions please give further information below.
Doctors Name*
Doctors Address*

Street Address

Street Address Line 2

Street Address Line 3County / State

Post / Zip Code
Doctors Phone Number*
I consent for Summit Guides to contact my Doctor*

YesNo
DIETARY REQUIREMENTS
Please list any dietary requirements*
FITNESS
Please list what exercise you do and how regularly*
MOUNTAIN ACTIVITIES EXPERIENCE
Please list any altitude, climbing, trekking, ski touring, mountaineering or wild camping experience. Include dates, grades and duration where possible*
RISK SUMMARY
It’s important to understand and accept the risks involved in our expeditions before booking. Specific risks associated with the mountain environment include: cold injuries & hypothermia, trips & falls, rock fall & water hazards. In winter, these also include avalanche and severe weather risks. On expeditions abroad, altitude sickness, poor hygiene & sanitation, remote access and less robust health systems are also factors. We put a huge amount of work into making our expeditions as safe as they can be, but risk cannot be removed entirely. The risks associated with your specific expedition can be discussed at the time of booking, will form part of your briefing at the start, and will be discussed while on the hill.
BOOKING CONDITIONS
I have read, understood and agree to the Booking Conditions. www.summitguides.com/booking-conditions
By ticking this box I show I have read and agree with the Booking Conditions
PARTICIPATION STATEMENT
When attending a Summit Guides expedition, participants recognise that: “climbing, hill walking and mountaineering are activities with a danger of personal injury or death. Participants in these activities should be aware of and accept these risks and be responsible for their own actions and involvement.” BMC Participation Statement www.thebmc.co.uk/risk-and-safety
By ticking this box I show I have read and agree with the BMC Participation Statement
CONSENT TO USE PHOTOGRAPHS AND MEDIA
As part of our services, Summit Guides may take photographs and videos of clients during the activities on our trips. These images and recordings may be used for promotional, marketing, and advertising purposes, including but not limited to our website, social media channels, printed materials, and other media.
1. I hereby grant Summit Guides the irrevocable, royalty-free, worldwide right and licence to use, reproduce, publish, and distribute photographs and/or video footage of me taken during the activity for marketing and promotional purposes.
2. I understand that these images may be used in various formats and media, including digital and print, and may be edited or adapted as necessary.
3. I waive any right to inspect or approve the finished product or the specific use to which the images may be applied.
4. I understand that I may withdraw this consent at any time by providing written notice to Summit Guides.
5. I release Summit Guides from any claims, demands, or liabilities arising out of or in connection with the use of the photographs or videos as described
Tick ONE option:*

By ticking this box I show consent to the use of photography and media in this wayBy ticking this box I show I DO NOT consent to the use of photography and media in this way
Participant Signature*

Clear
Date*

DayMonthYear
This form must be submitted at least 30 days before the start of your expedition.

This form must be completed, even if you have attended a Summit Guides course or expedition before (in case your circumstances have changed).
Should be Empty:

Participant Details: EXPEDITION

EXPEDITION

EMERGENCY CONTACT (NEXT OF KIN)

TRAVEL INSURANCE

MEDICAL

DIETARY REQUIREMENTS

FITNESS

MOUNTAIN ACTIVITIES EXPERIENCE

RISK SUMMARY

BOOKING CONDITIONS

PARTICIPATION STATEMENT

CONSENT TO USE PHOTOGRAPHS AND MEDIA