Information Request Form

Client Information Form

Hike Talk Stay Adventures
Full Name as on your Passport

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
What Size T-shirt do you wear
E-mail
example@example.com
Phone Number

Country CodeArea CodePhone Number
Date Of Birth

MonthDayYear
Date
Gender
Group Leader Full Name
Group or Private Trip (private trips are dedicated to your group)
Emergency Contact Name:
Emergency Contact Phone Number:
Accommodations:
Please detail your dietary restrictions & food allergies
Include restrictions that you do not eat, for example, no beef or halal only, lactose intolerance, severe allergies to specific foods etc, sulfa allergy if present and anything else we should be aware of.
Please write out your detailed medical history, type N/A for Safari only travelers. Please answer each question, providing detailed information on dates and type of medical treatment. Your signature on this form certifies that your statements below are true. 1. Have you ever had frostbite or any related cold weather injury/illness? □No □Yes. Please describe below: 2. Have you ever experienced any form of altitude illness? If so, please describe rate-of-ascent, altitude, medication and recovery procedures. □No □Yes. Please describe below: 3. List any major accidents, illnesses or operations you have had below: 4. List any/all physical/mental limitations or medical conditions that may restrict your ability to climb Kilimanjaro describe below: 5. Do you have back or knee problems? □No □Yes. Please describe below:
Type in your responses in the box above and please number them.
Enter the name of the person you will share a room with* If unknown currently, type unknown.
Dietary Requirements / Restrictions (if any)
Passport Number*
Passport Expiration Date*

MonthDayYear
Date
Upload a Scan or Photo of Your Passport*

Please provide a copy of your passport with all info visible and your photo. This is needed to complete you permits, bookings, and hotel stays.
Cancelof
Terms and Conditions: By checking this box, I acknowledge that I have read and agree to the Hike Talk Stays Terms & Conditions as listed here: https://www.hiketalkstay.com/termsconditions.
Signature
Name

First NameLast Name
Should be Empty:

Client Information Form