Monix Adventures - Booking form 

Trip details
Departure Date *
Departure Date
Personal Details
Name *
Name
DOB *
DOB
Address *
Address
Landline
Landline
Mobile *
Mobile
Emergency Contacts
Name *
Name
Landline *
Landline
Mobile *
Mobile
Expedition Experience
To help us understand your experience & comfort levels it is important that you fill in the following section with as much information as possible. If the section is not relevant to your expedition then please leave it blank. If you are concerned regarding the level of ability which is required then please contact Monix Adventures.
Please list experience relevant to this expedition, such as peaks climbed, notable routes (grades if known) and altitudes visited.
Ski Mountaineering Please indicate the level of difficultly you can ski on piste, list off piste/ glacier experience and number of days ski touring.
Medical Questionnaire
It is essential for us to know of any such condition for planning purposes. The following questions have been developed to provide information that may be helpful in assisting us in any medical situation involving you. With this in mind you are requested to provide all relevant details at this time and to advise us of any changes in your health/ fitness between now and the Expedition. If you are uncertain of any health matter please consult your own Doctor before booking.
1. Do you or have you ever suffered from the following? If you answer ‘yes’ to any of the questions please provide further details in the text box below.
Epilepsy/fits or blackouts *
Diabetes *
Recurrent ear or sinus problems *
Problems with mobility/lifting/carrying *
Heart/chest or lung problems *
Anxiety/depression or eating disorders or had to see a psychiatrist *
Blood Disorders *
2. Do you have Asthma? *
If so have you :
Please include inhalers and other medicines used
3. Have you had any operations? *
4. Have you had any serious illnesses requiring hospital admission? *
5. Have you had a head injury with loss of consciousness? *
8. Do you have any specific dietary requirements?
Security of information and use of images
To ensure the safe running of our Expeditions we need to use the information given on this form. We take full responsibility for ensuring that proper security measures are in place to protect this information when it is passed to our overseas subsidiary offices and third party suppliers. Any images taken of you whilst on our Expeditions, and images made available to us by you, may be used by us for marketing purposes.
Declaration
To the best of my knowledge and belief all information provided on this form is correct and I know of no reason(s) why I should not participate in the Expedition and will not be travelling against medical advice. In signing this form I confirm that I have read and understood the Monix Adventures Limited Terms and Conditions and confirm that I am willing to abide by them. I also confirm I have read and understood the payment schedule and agreed to the payment terms of this booking.
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