Application form for Operation Shangri-la 2009

Personal Particulars

*All fields are required unless indicated otherwise, enter n.a if not applicable.

Phase
   
Family Name As appears in Passport
Given Name As appears in Passport
NRIC No.
Foreign Identification No.
Passport No.
Passport Expiry Date  If 2009, please ensure it is renewed.
Date of Birth
Gender Male Female
Drug Allergy
Blood group
Email
   
Mailing address
 
Postal Code
Hand Phone No.
Home Phone No.
Fax No.
Nationality
Race
Religion
Marital Status
Occupation
Employer/ Institution
Frequent Flyer prog names/
numbers
Meal preference
Person To Notify In Case Of Emergency
   
Family Name
Given Name
Relation
Hand Phone No.
Home Phone No.
Office Phone No.
Pager No.
Address
 
Postal Code


Please describe your health and outdoor background.
   
Trekking Experience
Swimmer?
 
Have you ever had / Are you still having:
Heart disease / high blood pressure
Asthma, bronchitis, tuberculosis
Diabetes
Epilepsy, fainting attacks, migraine, severe head injury
Previous fractures, tendon/ligament damage
Previous operations
Suffering from or carrier of any infectious disease (e.g. hepatitis B)
Physical disabilities
On medications now (please give details and dosage below)
Other past illnesses
   

If you have answered “YES” to any of the above, please give details here:

  
 

ASSUMPTION OF ALL RISKS AND RELEASE OF LIABILITY

I am aware that my attendance in the expedition under the arrangements of X-Trekkers Adventure and its agents or associates, involves a certain amount of risk. It is also intended only for those without significant medical problems (including recent infections or injuries). I shall not hold the X-Trekkers' staff, agent or contractor responsible for any damage to or loss of property or any injury or loss of life which may be sustained by me during the expedition or arising from any cause in connection with the expedition.

I have also carefully read and do agree to all the conditions as stated under the heading “Terms and Conditions”, especially noting the policy on cancellations and refunds. I have also carefully read the above paragraphs, Assumption of All Risks and Release of Liability.