Information Request Form

Client Information Form

Hike Talk Stay Adventures
Name*

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)

I am booked on a shared group climb.I am booked on a private climb (has a group leader).I am booked on a private Safari (has a group leader and dedicated to your group)I am booked on a Safari package only
Emergency Contact Name:
Emergency Contact Phone Number:
Accommodations:

I made my reservation with someone else, and we will be sharing a tent and a double room with one larger bed.I made my reservation with someone else, and we will be sharing a tent and a twin room with two small beds.As an individual traveler, I am open to sharing a tent and a twin room with another traveler of the same gender. This room has two small beds.I am traveling alone, I have paid for the single supplement (get my own bed and tent for the trip).Our Private Group leader will create a list and pair every 2 together in a tent and for hotel.My accomodations were booked as part of my Safari package
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.
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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.*

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Client Information Form