Home  Kilimanjaro 2009 Print Registration Form
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Journeys of Inspiration
Mt. Kilimanjaro Climb
2009
TO REGISTER:
Because
we like to talk to anyone registering to answer any questions and to
get to know you a little, please call us week days at (585)346-5597
between 10:00 am and 3:00 pm EST. We can quickly get your registration
and credit card (VISA or Master Card) deposit information.
Other
ways to register would be: Please fill out the appropriate information
below and send it with your registration fee to: Pack, Paddle, Ski;
P.O. Box 82; South Lima, NY 14558-0082 or
E-mail us at
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NAME_____________________________________________________________________________________________
ADDRESS__________________________________________________________BOX NO. /APT #___________________
CITY_______________________________STATE________________________ZIP+4________________
DAY TIME PHONE______________________EVENING PHONE______________________ E-MAIL _______________________________
D.O.B.________SEX_______CONCERNS?_________________________________________ Y N
Amount
Deposit Required
Mt.
Kilimanjaro Climb: February 14 – Feb 26,
2009 $___2700____ $
___500______
Additional 3 Day Safari: February 25 – Feb 28 ,2009
$___1050____ $ ___100______
Additional
5 Day Safari: February 25 - Mar 2,
2009 $___1480____ $
___100______
Please send me a new registration page! YES NO TOTAL ENCLOSED $______________
I have read and understand the refund policy (see General Information in this newsletter)
___________________________________
Signature
PAYMENT METHOD (CIRCLE ONE)
CHECK VISA MasterCard Name on Card: _____________________________________________________
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Card Account Number
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Month Year
Signature
Expiration Date Required
EQUIPMENT I need to
rent: TENT SLEEPING BAG
RAINWEAR BACKPACK
HEALTH INFORMATION
Doctor's Name: Phone Number: Date of last physical ____________
Health Insurance Company Policy Number _________________________
Any Physical Restrictions? Allergies
Food Restrictions (be specific)
History of Heart/Respiratory Trouble?_____________________ Asthma?_____________ Diabetes?_______________
Medications currently being taken__________________________________________Dosages__________________
Are you currently being treated for anything?__________________________________________________________
Have you been treated for anything within the last 6 months?______________________________________________
Average weekly physical activity (type/duration)_______________________________________________________
EMERGENCY CONTACT
Name_______________________________Relationship__________________Phone (specify day/evening)____________________
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