Climb Denali | Adventure Consultants

Your name*

First*

Middle

Last*

Preferred name*

Date of birth*

Residential address*

State / Province / Region*

Zip Code*

Country*

Postal Address*

Same as residential address

State*

Zip*

Country*

Occupation

Email*

Sex

Weight*

Height*

T-shirt size

Phone numbers

Home*

Business*

Mobile*

Name

First*

Middle

Last*

Relationship to you*

Contact address*

State / Provice / Region*

Zip Code*

Country*

Phone numbers of your emergency contact

Home*

Business

Mobile

Passport number

Place of issue

Date of issue

Date of expiry

Place of birth

Nationality

Have you had any previous hospitalisation / surgery in the last 5 years?

Do you have any past injuries that could possibly affect your trip?

Are you taking any medications?

Do you have any medical conditions that we should know about?

If you answered to any of the above please provide details:

Dietary preferences

Level of fitness

Previous experience

How did you hear of Adventure Consultants?

Are you a current Alpine Club member?

Yes
No

I acknowledge that my booking is dependent upon me completing a signed and original Liability Release prior to the commencement of the trip.*

Your comments or questions please

Please read our Terms and Conditions

I have read, understood and agree to the terms and conditions detailed above*

Pay now with credit card.

On submission of this form you will be transferred to a secure payment gateway provided by Payment Express. Our credit card payments are in NZD dollars only (as we are a New Zealand based company) but we use the relevant USD or EUR to NZD exchange rate from the Bank of New Zealand.
Payment by credit card will also include a 3% credit card fee.
I will be paying by Bank transfer (Please provide me with bank account details)

Book Now

Trip Information

Contact details

Contact details in the event of an emergency

Passport details - International expeditions only

Medical & Dietary details

Other details

Deposit amount: