Kilimanjaro Registration

Kilimanjaro Registration Form

Traveler's Information

First Name *

As it appears on your passport

Middle Name

As it appears on your passport

Last Name *

As it appears on your passport

Preferred Name *

What name would you like to be called if different from your passport

Email *

Gender

Date of Birth

Month Day, Year

Passport Number *

Passport Country of Origin *

The Issue Date of Your Passport

Month Day, Year

Passport Expiration Date

Month Day, Year

Day Phone *

Occupation

Home Address *

Address Line 2

City *

State or Province *

Postal Code *

Country *

Height (in feet & inches)

Weight (in pounds)

Used for private charters/helicopters

Emergency Contact not traveling with you *

Your relationship to this person *

Emergency contact's phone number *

Do you plan to purchase Travel Insurance?

Yes

No

Travel Insurance Disclaimer *

I do not plan to purchase travel insurance, and I understand Barking Zebra Travel’s cancellation policy. I acknowledge that it is my responsibility to cover any costs for the loss of personal luggage, money, and goods, as well as medical expenses, theft, damage, cancellation, or curtailment of the adventure. I understand that I will be charged directly by the relevant service provider for any medical and emergency services I may require, including but not limited to hospitalization, transportation, and additional lodging.

Are you allergic to any medications?

Yes

No

Allergies to medications

Do you have any other known allergies? (Food, Air-born, etc.)

Yes

No

Known allergies

Do you have any dietary requirements?

Yes

No

Dietary Requirements

Medical Information

Please answer each of the following health questions by providing detailed information that includes dates and medical response. Please let us know of any changes!

Have you ever experienced any form of altitude sickness? *

Yes

No

Have you ever experienced any form of altitude sickness?

In the past two years, have you had any major accidents or illnesses? *

Yes

No

In the past two years, have you had any major accidents or illnesses?

Do you have any physical limitations or medical conditions that might restrict your full participation in this trek? *

Yes

No

Do you have any physical limitations or medical conditions that might restrict your full participation in this trek?

Do you have any knee problems? *

Yes

No

Do you have any knee problems?

Will you be taking any medications during this trip? *

Yes

No

Will you be taking any medications during this trip?

ADDITIONAL COMMENTS:

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