FULL NAME AS PER PASSPORT
*
Email
*
YOUR DIRECT CONTACT NUMBER
*
GENDER
*
DATE OF BIRTH: MM/DD/YY
*
PASSPORT NUMBER
*
NATIONALITY AS PER YOUR PASSPORT
*
COUNTRY OF RESIDENCE
*
CITY OF RESIDENCE
*
MEAL OPTION (CHOOSE ONE)
*
VEGETARIAN
MEAT (BEEF, CHICKEN, VEGETABLES)
HEIGHT IN CENTIMETERS
*
CURRENT WEIGHT IN KG
*
PROVIDE ANY HEALTH ISSUES THAT YOU HAVE: This tour will take you to the remote jungle, so your health condition is very important to us. You are required to provide accurate information. We will keep it private and confidential.
*
WHEN WAS THE LAST TIME YOU HAD A HEALTH CHECK?
*
DO YOU HAVE HIGH BLOOD PRESSURE? IS IT WELL-CONTROLLED BY MEDICATION?
*
DO YOU HAVE ANY HEART DISEASE OR HEART CONDITIONS?
*
DO YOU HAVE DIABETES? IF YOU DO, PLEASE STATE IF TYPE 1 OR TYPE 2, AND WHETHER IT IS UNDER CONTROL BY MEDICATION/DIET.
*
PLEASE LIST ALL PRESCRIBED AND OVER-THE-COUNTER MEDICATIONS YOU TAKE OR INJECT DAILY, WITH DOSAGE AND FREQUENCY. DO NOT INCLUDE HERBAL MEDICINE, BIRTH CONTROL, OR DIETARY SUPPLEMENTS
*
DURING THE PAST 5 YEARS, HAVE YOU SUFFERED ANY SIGNIFICANT OR RECURRING ILLNESS.
*
ARE YOU WAITING FOR ANY HOSPITAL APPOINTMENTS OR TESTS?
*
DO YOU HAVE ANY SPEAKING OR HEARING PROBLEMS?
*
DO YOU HAVE ASTHMA, OTHER BREATHING PROBLEMS, OR EPILEPSY?
*
DO YOU HAVE CLAUSTROPHOBIA OR ACROPHOBIA (FEAR HEIGHTS)?
*
DO YOU HAVE PROBLEMS WITH YOUR HANDS, LEGS, BACK, OR JOINTS THAT MAKE IT DIFFICULT TO WALK OR HOLD OBJECTS?
*
DO YOU HAVE ANY ALLERGIES TO MEDICAL DRUGS, FOOD, INSECT BITES OR PLANTS?
*
DO YOU CARRY AN EPIPEN?
*
DO YOU HAVE ANY OTHER MEDICAL OR FITNESS CONDITIONS NOT LISTEN ABOVE?
*
If you answered "Yes" to any of the above questions, please provide details here. Especially if you have allergies, please provide specific details.
*
YOUR TREKKING EXPERIENCE - Some guests were unable to complete this adventure tour due to personal fitness issues. Please ensure that you have prior trekking experience and are physically fit for this tour.
*
In the past 12 months, have you done at least 1 overnight camping trek AND 1 one-day hike, covering at least 8km (~5 miles) per day through forests, mountains, rocky or steep terrains, with an elevation gain of at least 300m?
*
Please describe your trekking activities in the past 12 months. Include the route location, time, number of days, distance, terrain, and elevation gain.
*
Can you run 5km in 50 minutes or walk it in 75 minutes, and climb 5 floors without getting out of breath or dizzy?
*
Do you regularly exercise or play sports? Please list them below with the frequency and intensity
*
I will regularly engage in physical training to fit this adventure tour.
*
Can you swim?
*
Please list any special requirements you have for the trip
*
*
