Group Trek Form Personal InformationName of Group Trek* Name* First Last Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePrefer Not to AnswerOccupation* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Home PhoneMobile Phone*Room AssignmentI would like to share a room with: I would like to share a room: Transformational Trekking (TT) will match you with another trekker (most likely you will switch roommates each night). However, if we have odd numbers we cannot guarantee that you will be able to share a room. In that case you will be charged the single room supplement (amount listed on your trip itinerary).I have requested a single room and TT has verified that one is available. Verified with TTEmergency Contact DetailsName of Emergency Contact* Emergency Email Address* Emergency Phone*Health QuestionnnaireSickness or muscular-skeletal injuries in the past 3 years.*Any health related or pre-existing conditions?* YES NO **If you answered YES to the above question, a physician questionnaire from your doctor is required. Transformational Trekking will send this questionnaire to you. Please provide details about any health related or pre-existing conditions:*Other medical conditions that require a physician questionnaire from your doctor:Do you currently have and/or have experienced any of the following conditions? Palpitations / chest pain Blood Disorder Heart Condition Stroke Diabetes Dizziness or Fainting Liver or Kidney conditions Epilepsy Cancer (Recent) Details of Condition(s) (if any)Do you have allergies or foods that you can’t eat?*Any life threatening allergies (such as to bee stings or nuts)? Do you carry an epi-pen or other device?*List any medications that you are taking:*List any medications that you are allergic to:*Do you have asthma and, if so, how do you regulate it?*Have you had any surgeries in the past three years?*Do you have a phobia/fear of something? If you do, please provide details:*Previous Trekking ExperiencePlease share your previous trekking experiences of three or more days in a row:*What is the longest day-hike you have completed?* What is your average mile per hour pace while walking on flat surfaces?* What is your average mile per hour pace while on hillier hikes/walks?* Special Note: A training plan will be provided to help you prepare for this trekking adventure. Following the plan will help you build cardiovascular and muscular endurance for hilly pathways and for the longer days on the trail. Any long distance trek has its challenges and requires a certain level of fitness. If you know you will not have time to train for this trek, I ask that you wait to do this trek at a time when you can train. Transformational Trekking offers individualized training programs that go over more than the hiking build-up plan that is provided. The individualized program is at an additional cost. Transformational Trekking also offers out-door group trek training for women in parks to help prepare for treks like this one. This opportunity is also at an additional cost. To find out more about how to train for this trek, email Sheri of Transformational Trekking at: [email protected]CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
