Challenge name*

Charity name

Date of trip*

Passport photo

Full passport name

Email address

Nationality*

Passport number

Date of birth*

Date of issue

Date of expiry

Place of issue

Height*:
—Please choose an option—4'4'1"4'2"4'3"4'4"4'5"4'6"4'7"4'8"4'9"4'10"4'11"5'5'1"5'2"5'3"5'4"5'5"5'6"5'7"5'8"5'9"5'10"5'11"6'6'1"6'2"6'3"6'4"6'5"6'6"6'7"

Weight*:
—Please choose an option—6 stone 0 lbs6 stone 1 lbs6 stone 2 lbs6 stone 3 lbs6 stone 4 lbs6 stone 5 lbs6 stone 6 lbs6 stone 7 lbs6 stone 8 lbs6 stone 9 lbs6 stone 10 lbs6 stone 11 lbs6 stone 12 lbs6 stone 13 lbs7 stone 0 lbs7 stone 1 lbs7 stone 2 lbs7 stone 3 lbs7 stone 4 lbs7 stone 5 lbs7 stone 6 lbs7 stone 7 lbs7 stone 8 lbs7 stone 9 lbs7 stone 10 lbs7 stone 11 lbs7 stone 12 lbs7 stone 13 lbs8 stone 0 lbs8 stone 1 lbs8 stone 2 lbs8 stone 3 lbs8 stone 4 lbs8 stone 5 lbs8 stone 6 lbs8 stone 7 lbs8 stone 8 lbs8 stone 9 lbs8 stone 10 lbs8 stone 11 lbs8 stone 12 lbs8 stone 13 lbs9 stone 0 lbs9 stone 1 lbs9 stone 2 lbs9 stone 3 lbs9 stone 4 lbs9 stone 5 lbs9 stone 6 lbs9 stone 7 lbs9 stone 8 lbs9 stone 9 lbs9 stone 10 lbs9 stone 11 lbs9 stone 12 lbs9 stone 13 lbs10 stone 0 lbs10 stone 1 lbs10 stone 2 lbs10 stone 3 lbs10 stone 4 lbs10 stone 5 lbs10 stone 6 lbs10 stone 7 lbs10 stone 8 lbs10 stone 9 lbs10 stone 10 lbs10 stone 11 lbs10 stone 12 lbs10 stone 13 lbs11 stone 0 lbs11 stone 1 lbs11 stone 2 lbs11 stone 3 lbs11 stone 4 lbs11 stone 5 lbs11 stone 6 lbs11 stone 7 lbs11 stone 8 lbs11 stone 9 lbs11 stone 10 lbs11 stone 11 lbs11 stone 12 lbs11 stone 13 lbs12 stone 0 lbs12 stone 1 lbs12 stone 2 lbs12 stone 3 lbs12 stone 4 lbs12 stone 5 lbs12 stone 6 lbs12 stone 7 lbs12 stone 8 lbs12 stone 9 lbs12 stone 10 lbs12 stone 11 lbs12 stone 12 lbs12 stone 13 lbs13 stone 0 lbs13 stone 1 lbs13 stone 2 lbs13 stone 3 lbs13 stone 4 lbs13 stone 5 lbs13 stone 6 lbs13 stone 7 lbs13 stone 8 lbs13 stone 9 lbs13 stone 10 lbs13 stone 11 lbs13 stone 12 lbs13 stone 13 lbs14 stone 0 lbs14 stone 1 lbs14 stone 2 lbs14 stone 3 lbs14 stone 4 lbs14 stone 5 lbs14 stone 6 lbs14 stone 7 lbs14 stone 8 lbs14 stone 9 lbs14 stone 10 lbs14 stone 11 lbs14 stone 12 lbs14 stone 13 lbs15 stone 0 lbs15 stone 1 lbs15 stone 2 lbs15 stone 3 lbs15 stone 4 lbs15 stone 5 lbs15 stone 6 lbs15 stone 7 lbs15 stone 8 lbs15 stone 9 lbs15 stone 10 lbs15 stone 11 lbs15 stone 12 lbs15 stone 13 lbs16 stone 0 lbs16 stone 1 lbs16 stone 2 lbs16 stone 3 lbs16 stone 4 lbs16 stone 5 lbs16 stone 6 lbs16 stone 7 lbs16 stone 8 lbs16 stone 9 lbs16 stone 10 lbs16 stone 11 lbs16 stone 12 lbs16 stone 13 lbs17 stone 0 lbs17 stone 1 lbs17 stone 2 lbs17 stone 3 lbs17 stone 4 lbs17 stone 5 lbs17 stone 6 lbs17 stone 7 lbs17 stone 8 lbs17 stone 9 lbs17 stone 10 lbs17 stone 11 lbs17 stone 12 lbs17 stone 13 lbs18 stone 0 lbs18 stone 1 lbs18 stone 2 lbs18 stone 3 lbs18 stone 4 lbs18 stone 5 lbs18 stone 6 lbs18 stone 7 lbs18 stone 8 lbs18 stone 9 lbs18 stone 10 lbs18 stone 11 lbs18 stone 12 lbs18 stone 13 lbs19 stone 0 lbs19 stone 1 lbs19 stone 2 lbs19 stone 3 lbs19 stone 4 lbs19 stone 5 lbs19 stone 6 lbs19 stone 7 lbs19 stone 8 lbs19 stone 9 lbs19 stone 10 lbs19 stone 11 lbs19 stone 12 lbs19 stone 13 lbs20 stone 0 lbs20 stone 1 lbs

Raised blood pressure*:
yesno

Heart or circulatory failure*:
yesno

Blood clots - in particular, DVT (clot in leg) or PE (clot in lung)*:
yesno

Chest or lung disease*:
yesno

Asthma*:
yesno

Epilepsy*:
yesno

Diabetes*:
yesno

Digestive or bowel disorders*:
yesno

Haematological or blood disorders*:
yesno

Cerebral disease e.g. stroke, head injury, tumour*:
yesno

Past injuries e.g. fractures or sprains*:
yesno

Operations*:
yesno

Mental health problems*:
yesno

Allergies*:
yesno

Heat or cold injury*:
yesno

Please list any medication you are currently taking (if none, state ‘none’)*
none

If you have any other medical conditions not disclosed above, please give further details. For any medical conditions that have
been disclosed above please give further details:

Comments:

Dietary requirements*

First name*

Last name*

Relationship*

Daytime phone number*

Evening phone number*

Mobile phone number*

Email

Are you taking part in a high-altitude trip?
yesno