The programme in which you will participate requires a good fitness, power and resistance level. It is your responsibility to ensure that you have an appropriate physical condition to allow you to participate. Should it be necessary, please do consult a doctor to ensure that your health and physical conditions are suitable to be able to participate in a programme of this type. All of the information revealed will be treated with absolute confidentiality. Name Date of birth Passport/ID Number Occupation Address Mobile phone number Home phone number Emergency Contact and relation Emergency contact phone number Email 1. Are you allergic to any medicine? YES NO 1. Are you allergic to any medicine? YES NO 2. Eating disorders YES NO 3. Do you suffer from hepatitis or any other liver disease? YES NO 4. Do you suffer from neurological disorders such as epilepsy or convulsions? YES NO 5. Do you suffer from dizziness or fainting spells? YES NO 6. Do you suffer from cardiovascular diseases? YES NO 7. Does your family have a history of cardiovascular diseases? YES NO 8. Do you suffer from high blood pressure? YES NO 9. Does your family have a history of high blood pressure? YES NO 10. Do you suffer from gastrointestinal diseases? YES NO 11. Do you suffer from diabetes? YES NO 12. Do you have any allergies? YES NO 13. Do you smoke? YES NO 14. Do you have respiratory problems? YES NO 15. Do you have high cholesterol levels? YES NO 16. Have you suffered any injuries to ankles, knees, back, hips, etc.? YES NO 17. Have you ever had any altitude related problems? YES NO 18. Blood type (if you know it) YES NO 19. Do you have any earing problems? YES NO If you answered “yes” to any of the above questions or have had undergone medical treatment, please provide more detail and mention any medicine that you are currently taking. Send All the above information is correct. I understand that not providing full details may compromise my health and safety during the trip and may result in a premature termination of the programme. I agree to informing AndesContact should any of the above details have changed before the start of the trip. I give my consent to receive medical attention or treatment from a doctor or treatment and for a family member to be notified in the case of hospitilisation should I become injured or fall ill during any programme of AndesContact. This form should be signed upon the start of the programme.