APPLICATION

ADOBE PDF VERSION
Aplication complete and return to our mail, or send to our fax 56-2-2341092, or PRINT and send to:

ANDES MOUNTAIN EXPEDICIONES

Santiago, Chile

www.andesmountain.cl         andes@andesmountain.cl
Name, and date of Your trip_______________________________________________________________________________

Name____________________________________________________________________________________________________

Address__________________________________________________________________________________________________

Country__________________________________________________________________________________________________

Telephone_________________________email________________________Age_______Height________Weight__________

Birth date_________/_____________/________________

Sex     Male________Female________      Nationality_________________________________________________________

Occupation________________________________________________Passport #_____________________________________

Hotels     Share room (double occupancy)________________
              Fee suplement for single room ________________

In case of an emergency notify:

Name__________________________________________________Telephone________________________________________

Address__________________________________________________________________________________________________

Do you have any allergies?_________If yes, explain__________________________________________________________

Are you taking any medication?________If yes, explain_______________________________________________________

Medical history____________________________________________________________________________________________

__________________________________________________________________________________________________________

Outdoor Experience________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Climbing/Trekking experience and other high mountaineering peak only (Peak, Route, Date) -Please complete this if you are signing up for a mountaineering

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________
 

Signature____________________________________________________________Date_________________________