TRIP APPLICATIONKhangri Experience, LLC reserves the right to deny participation to any participant until full review of their Registration Documents is complete. PARTICIPANT INFORMATION: Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Age * Primary Contact Phone Number * (###) ### #### Email * Gender * Male Female Height * - 5ft. 5ft 1in 5ft 2in. 5ft 3in. 5ft 4in. 5ft 5in. 5ft 6in. 5ft 7in. 5ft 8in. 5ft 9in. 5ft 10in. 5ft 11in. 6ft. 6ft 1in. 6ft 2in. 6ft 3in. 6ft 4in. 6ft 5in. 6ft 6in. 6ft 7in. 6ft 8in. 6ft 9in. 6ft 10in. 6ft 11in. 7ft. 7ft 1in. 7ft 2in. 7ft 3in. 7ft 4in. 7ft 5in. 7ft 6in. 7ft 7in. 7ft 8in. 7ft 9in. 7ft 10in. 7ft 11in. 8ft. Weight * T Shirt Size * Occupation * Marital Status * Passport # Passport Issuing Country Passport Issue Date MM DD YYYY Passport Expiration Date (Must be valid for 6 months after departure) MM DD YYYY Trip Information: Expedition/Treks * Amadablam Annapurna Base Camp & Gorepani Cho-oyu Everest Everest Base Camp Gokyo Lake and Renjo Pass Island Peak Khumbu Classic Kilimanjaro Manaslu Mera Peak Mt Baker Mt Rainier Private Basic Mountaineering Class Everest base camp/ Gokyo/ Renjo pass For Private, Please list what Expedition/Trek you are interested in: Requested Primary Departure Date * MM DD YYYY Requested Secondary Departure Date: MM DD YYYY EMERGENCY CONTACT INFORMATION: Contact Name * Relationship to Participant * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone Number * INSURANCE INFORMATION: Type of Insurance Insurance Provider Policy No. Medical Information: Please list any accidents, operations, or illnesses you have had in the past. Please note if you have been hospitalized for any of these. * Please list any food or drug allergies. * Will you require any form of allergic medication for treatment? If so, Please plan to bring them on the climb. * Yes No Any medications participant is taking * Vaccination Status * Vaccinated Unvaccinated Do you have any of the following? If more than one, please list them on the box below * Ankle Problems Arm & Shoulder Problems Back Problems Cancer Circulation Problems Head trauma, Injury, Chronic Migraines and Headaches Hearing or Vision Impairment High or Low blood pressure, Heart Condition, Blood disease or irregular heartbeat Internal problems (Diabetes, Hypoglycemia, Intestinal or Kidney problems) Joint dislocations Knee Problem Neck Problem Respiratory issues Seizure Disorder None Please list and describe any dietary restrictions * Are you currently under the care of or have a history of treatment from a mental health professional? Please describe. * Have you experienced any altitude sickness before? * Yes No Have you ever had frostbite or any related cold weather injury/illness? * Yes No Do you wear any prescription glasses? * Yes No CLIMBING INFORMATION: Please list any mountaineering or climbing experience, including any courses or training that you have completed. * Please list any mountains that you have scaled within the past 2 years. By checking this box, I affirm and certify that the above medical information is correct. * Agree Disagree I affirm and certify that I have the required training and physical fitness level to perform this expedition * Agree Disagree Thank you for your interest! We will review your application and email you back as soon as possible.
