Trek Peru’s Ausangate Circuit and Rainbow Mountain, 5/31/2020 - 6/13/2020 APPLICATION

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Name

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Phone Number

Mailing Address

Age Please enter your age in years.

Gender Please enter your gender.

Height Please enter your height in feet and inches (e.g. 5 ft 6 in)

Weight Please enter weight in pounds.

Recent Backpacking or Multi-day Trekking Experience Please include length, elevation, miles per day, and weight carried for backpacking or multi-day trekking trips you've done in the last two years.

Typical Backpack Itinerary Please indicate your typical hike or backpack itinerary—average daily mileage (miles), elevation gain (feet), and pace (miles/hour).

Other Outdoor Activities If you have limited recent backpacking experience, please describe any other active outdoor activities you have pursued regularly (hiking, scrambling, climbing).

International Travel Experience Please describe your international travel experience, particularly indicating what trips were with groups and whether they were family & friends, commercial, or other.

High Altitude Experience Please describe any experience you have with multiple days of walking, trekking, backpacking, or climbing where you slept multiple nights above 12,000 ft, the maximum altitude you have attained, and any symptoms that you have experienced at high altitudes.

Goals What are your personal goals and objectives for this outing? Tell us what you'd like to get out of this trip.

Medical Conditions Please describe any medical conditions, joint or back issues, recent surgeries, allergies or medications that could affect you on the trip.

Fitness Program Please describe your regular fitness program.

Dietary Requirements Please list any special dietary preferences or requirements for the trip.

Information Sharing The above information will be kept strictly confidential by the leader, with one exception: If medical treatment is required onsite during a global adventure, it may be important to share information on the physical fitness, medications, allergies and medical conditions of participants to aid in treatment. May the leader share this information with first aid and medical personnel in an emergency situation?

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Trek Peru’s Ausangate Circuit and Rainbow Mountain, 5/31/2020 - 6/13/2020 APPLICATION

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