Health, Insurance, Participation Statement - Trek Climb Explore

Health & Participation

Health form & Participation Statement

Booking Reference*
This is the surname of the person who initially made your group's booking
Personal Details
Name*
First Last
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Date of Birth*
MM
DD
YYYY
Mobile Phone*
Preferably give us the phone number you will bring with you to Morocco
Whatsapp

Can we contact you on whatsapp? What is your Whatsapp number (if different from above). This is usually the way we will communicate last-minute information or changes of plans with you. Put "none" if you don't have whatsapp.
Home Phone
Email*

Next of Kin Details
In case of an emergency
Name*
First Last
Relationship to you*
Home Phone*
Mobile Phone*
Email*
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Medical Declaration
This is purely confidential. We need to be aware of this in case of emergency, not to stop you doing something you want to do!
Do you have, or have you had any of the following conditions? If yes please give details:*
- Diabetes
- Asthma
- Epilepsy
- Heart Disease
- Back Injury
- Food Allergy
- Drug Allergy
- Anaphylactic shock
- No Issues
Details
Please list any other sickness, injury, medical conditions, disease or treatments that required hospitalisation within the last 12 months:
Please list medications you are taking at this time
Note: it is your responsibility to bring your regular medication along, and to inform your leader of its whereabouts during your trip.
Any special dietary Requirements?
How do you describe your general health?*
(1=not very healthy, 5=very healthy)
How do you describe your general fitness?*
(1=unfit, 5=very fit)
Previous Experience
Briefly summarise your mountaineering / trekking / running experience relevant to your trip:

Insurance
Wild Goose Adventure SARL adheres to Moroccan law in regard to public liability insurance. We require our clients to have personal travel insurance for the duration of their trip including cover for helicopter evacuation and rescue. Please provide details:
Name of Insurance Company*
Policy number*
Emergency Claims Phone Number*
Participation Statement
Wild Goose Adventure recognises that Trekking, Running, Climbing 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.
I recognise that Wild Goose Adventure operates in remote and isolated environments in the Atlas Mountains, Morocco. I understand that there is no public provision of Mountain Rescue services in Morocco. I accept that Wild Goose Adventure will do their best to discharge their duty of care in an emergency, but that European standards of evacuation and emergency care are not necessarily available in Morocco. Wild Goose Adventure SARL is a registered Moroccan limited liability company. I accept that any claim or dispute arising from this contract will be settled in Moroccan courts under Moroccan law.
*
You must agree in order to submit the form. If there are aspects of this that you are not sure about please email us directly and we will address your concerns. info@wildgooseadventure.com
- I have read and agree to the Terms and Conditions
Signed*
I recognise that Wild Goose Adventure operates in remote and isolated environments in the Atlas Mountains, Morocco. I am aware of and accept these risks and take full responsibility for my own actions and involvement. I understand that there is no public provision of Mountain Rescue services in Morocco. I accept that Wild Goose Adventure will do their best to discharge their duty of care in an emergency, but that European standards of evacuation and emergency care are not necessarily available in Morocco.

Health & Participation

Step 1 of 4

Personal Details

Next of Kin Details

Medical Declaration

Insurance

Participation Statement

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