Expedition Code

General Information

         Name

First
Middle
Last

Choose One Mexico - Mountaineering School (Jan 3 - Jan 17, 2009) MXMS-09-01030117 Bolivia - Mountaineering School (Jun 5 - Jun 20, 2009) BVMS-09-06050620 Bolivia - Mountaineering School w/ Extension (Jun 5-Jun 26, 2009) BVMSX-09-06050626 Ecuador - Mountaineering School (Jan 2 - Jan 14, 2009) EDMS-09-01020114 Ecuador - Mountaineering School w/ Extension (Jan 2 - Jan 22, 2009) EDMSX-09-01020122 Ecuador - Mountaineering School (Jun 5 - Jun 17, 2009) EDMS-09-06050617 Ecuador - Mountaineering School w/ Extension (Jun 5 - Jun 25, 2009) EDMSX-09-06050625 Peru - Mountaineering School (Jul 18 - Aug 2, 2009) PRMS-09-07180802 Peru - Mountaineering School w/ Extension (Jul 18 - Aug 9, 2009) PRMSX-09-07180809 Argentina - Aconcagua, Polish Traverse (Jan 9 - Jan 31, 2009) AGPV-09-01090131 Argentina - Aconcagua, Ruta Normal (Jan 9 - Jan 31, 2009) AGRT-09-01090131

  Address

Street
City
State/Province
Zip/Postal Code
Country

  Contact

Home Phone
Work
Cell
Email

 

Passport Information

Name (as it appears on passport)

First
Middle
Last
Passport No.
Expiration Date

Country

Place Of Issue
Date Of Issue
Place Of Birth
Additional Citizenship

 

Medical Certification                                                  (check your highest current medical certification)

WFR    OEC    EMT    EMT-I    WEMT

EMT-P  PA/NP MD/DO

We are pleased to offer significant discounts to practicing medical professionals (some conditions apply).

Yes, I would like more information.

 

Notice to Single Travelers

All prices are based on double occupancy. If you are traveling solo we will make a reasonable effort to place you with a same-gender roommate. If such an arrangement is not possible due to incompatibility or roommate cancellation, you will be assessed a single supplement fee.

Yes, those are all the options. No, there are no others. Pull up your big girl panties and suck it up, princess.

I am    am not   a single traveler.

 

Climbing Resume

Proficiency

Beginner   Intermediate   Advanced

Frequency

Daily     Weekly     Monthly     Annually

Style/Difficulty

Trad   

Sport  

Aid     

Ice      

Mixed

Grade

I   II   III   IV   V   VI

Recent Climbs

List five rock routes you have completed in the past year. Include route name, difficulty rating, grade and location.

1.

2.

3.

4.

5.

List five mountaineering or alpine routes you have completed in the past year. Include route name, difficulty rating, grade and location.

1.

2.

3.

4.

5.

Highest Altitude Climbed

meters   feet

 

Electronic Signature

I adopt the mark typed in the form below as my electronic signature. By signing in the box below I  declare (or certify, verify, or state) pursuant to Title 28 U.S.C. §1746, under penalty of perjury under the laws of the United States of America, that the foregoing representations are true and correct.

 Enter your full name (E-sign):