Participant Information & Screening

Please complete all sections accurately. This form is used to assess trip suitability, safety requirements, and operational needs.

Last updated: 3 December 2025

1 — Personal Details

Full Name

Date of Birth

Gender

Nationality

Residential Address

Phone (with country code)

Passport Number

Country of Issue

Passport Expiry Date

2 — Emergency Contact

Full Name

Relationship

Phone (with country code)

3 — Insurance Details (Mandatory)

Insurance Provider

Policy Number

24/7 Emergency Assistance Number

Coverage includes (tick all that apply)

4 — Medical Disclosure

Medical Conditions (even if controlled)

Current Medications

Allergies

Dietary Requirements

HAVE YOU BEEN ADVISED BY A DOCTOR NOT TO PARTICIPATE IN HIGH ALTITUDE AND / OR STRENUOUS ACTIVITIES?

Yes No

If yes, details

Have you experienced altitude illness before?

Yes No

If yes, describe

Hours of exercise per week

6 — Expedition Details

Expedition / Program Name

Start Date

End Date

Preferred Group Size (if applicable)

7 — Payment Method

Bank transfer (Australia) International bank transfer Wise PayPal

8 — Document Checklist

Please confirm the following documents are attached or will be provided:

Passport copy Insurance certificate Completed medical section Flight itinerary (if booked) Signed Waiver & Risk Acknowledgement

9 — Confirmation & Declaration

I declare that:

All information provided is true and complete.
I have reviewed and accept the Nomads of Altitude Terms & Conditions.
I have read, understood, and signed the Waiver & Risk Acknowledgement.
I understand that inaccurate information may affect my participation.

Participant Name

Signature

Date

By submitting this form you confirm that all information provided is accurate and complete.

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Participant Information & Screening

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