Note:
- Fields marked with ' * ' are mandatory and need to be completed before form can be processed.
- 'REFRESH' or 'RELOAD' your browser to ensure that this is the latest version of this form.

PERSONAL PARTICULARS
Name ( in full as printed in Passport )	*
Primary Email Address	*
Secondary E-mail Address  ( should the above email address be invalid )
Contact No. ( ie. Mobile Phone )	*
Address	*
Country
Postal Code	*
Date of Birth ( dd-mm-yyyy )	*
Nationality
Passport Number
Passport Expiry Date
Gender	*	[ please select applicable value ] Male Female
Marital Status	*	[ please select applicable value ] Single Married
Profession / Job Title	*
Swimmer Status		[ please select applicable value ] Non Swimmer Poor Swimmer Average Swimmer Strong Swimmer
CONTACT REFERENCE FOR EMERGENCY ( this section must be completed by all applicants )
Blood Group	*
Next of Kin's Name	*
NOK's Contact No.	*
NOK's Relationship to Participant	*	[ please select applicable value ] Mother Father Spouse Brother Sister Friend Guardian Others
OUTDOOR EXPERIENCE ( complete section if you're applying to join an overnight trekking trip, otherwise please skip)
Pls tell us more about your outdoor & travel experience
General travel / backpacking
Trekking

PRELIMINARY TRAVEL FITNESS QUESTIONNAIRE

All treks to Malaysian waterfalls & mountains require active participation to a greater or lesser degree. It is in the interest of all members of the group that everyone should be capable of fully participating in the activities of their chosen events.

TREKKING FITNESS ( please complete this only if you are joining a trekking or overland trip )

What is your current physical fitness level on a scale of 1 - 6 ?
[ please select applicable option ] Level 1 - Couch Potato. Haha ... what is exercise ? Level 2 - Exercise 1-2 times every month Level 3 - Exercise 1-2 times every 2 weeks Level 4 - Exercise 1-2 times every week Level 5 - Exercise 3-4 times every week Level 6 - As Fit As A Triathete

How do you presently keep fit and what fitness plan you have in mind to prepare for this trek ?


MEDICAL FITNESS ( please complete for all events )

It is recommended that you undergo a medical examination before undertaking any major outdoor event or program. Your medical examination should be done not more than 1 year before the event or program. You should also consult a Medical Doctor to re-assess your fitness if you have contracted any illness or disease between the medical examination and the commencement of the event. It is your responsibility to keep the organizers informed.

Do you have any past / present injuries or serious illness or physical / medical impairment or allergies that may interfere with or limit your participation in the event.   None of these will necessarily prohibit your participation, but for your own safety, we must be aware of such conditions.

Physical Impairment (s)	[ please select applicable value ] No impairment Eyesight Hearing Joints ( knee / ankle / hip etc.) Back problem Leg / Foot problem Others ( please give details below )
Medical Impairment (s)	[ please select applicable value ] No impairment Hyper-tension High blood pressure Low blood pressure Diabetes Respiratory disorder ( asthma / bronchitis ) Migraine Depression spells Blackouts / Fainting spells ( give details below ) Gastro-Intestinal problems ( give details below ) Acrophobia Viral Carrier ( please give details below ) Others ( please give details below )
Allergy	[ please select applicable value ] No allergy Insect stings Food allergy Aspirin allergy Panadol allergy Penicillin allergy Iodine allergy G6PD deficiency Others ( please give details below )

Detailed description of Impairments or Allergies, including any others not mentioned. Please also indicate when the last occurrence of the illness / allergy took place


If you are presently taking a prescriptive medication, please list medical condition for which this medicine was prescribed for and name of medication

DIETARY CONDITION ( please complete only if you are joining an overnight event )

Please tick any / all Dietary Restriction(s) that apply to you

No Restriction

No Beef

No Pork

No Mutton

No Seafood

Vegetarian

Others

BOOKING CLAUSES AND CONDITIONS

Please read the following carefully before sending in your application

Payment And Cancellation Clause

Payment is immediately due upon booking. You may cancel the booking at any time provided that the cancellation is communicated to us in writing.  We calculate your refund on the day we receive your written notice of cancellation. 8 days & more: No Charge 07 days or less prior to departure: $30 If we cancel the outing due to insufficient participants or other reasons, a full refund will be given.


Liability Release and Assumption of Risk Agreement

I acknowledge that I have voluntarily chosen to participate in the abovementioned activity on my own accord. In so doing, I acknowledge that I may be subjecting myself to certain dangers and hazards which could result in illness, injury or death. I also acknowledge that there are inherent risks and dangers, including but not limited to the hazards of traveling in mountainous terrain, accidents or illness in remote places, forces of nature, and the actions of participants and other persons, which may arise at any time during the event.  I am specifically familiar with and accept the risks of the dangers and hazards both mentioned and implied. In consideration of and as part payment for the right to participate in the abovementioned activity, I agree to assume all risks of illness, injury or death and agree not to sue and to RELEASE FROM LIABILITY AND INDEMNIFY the organizers, their agents, contracted tour operators and other persons or entities involved with this event and / or programme, from all actions, claims or demands for injury, loss or damage regardless of the cause resulting from my participation in the event and / or programme. The terms of this agreement shall serve as a release and assumption of risk binding on my heirs, executor, administrator and all members of my family, including any minors accompanying me. DECLARATION:- I declare that all the information given by me in this application for activity is true to the best of my knowledge and that I have not withheld any relevant particulars. I have disclosed all the information required to be given in this application.  This declaration shall be part of my contract with the organizers. I accept that if any of the information given by me in this application is in any way false or incorrect, the organizer(s) shall have the right to reject this application, and/or hold no liability of any form, whatsoever. Compensation will be at discretion of the organizer(s).


Usage of Materials Agreement

I grant the organizers the absolute right to use, copyright, re-use, publish and republish by any medium, including electronically and through the internet, my personal travel notes or journals that I have made available to fellow team members, and any photos of me or in which I may be included that may be taken while participating in this event. I also consent to the use of any printed matter in conjunction therewith.

Acceptance of Agreement

Yes, I hereby accept and agree to abide by this agreement

Please click the following submission button ONCE only ... and please be patient as sometimes, the email server may be a bit slow :-)