REGISTRATION SHEET AND HEALTH STATEMENT

REGISTRATION AND HEALTH CARD

PERSONAL DATA AND IDENTIFICATION DOCUMENT

DATE

NAMES

SURNAME

AGE

SEX

PHONE

EMAIL *

ADRESS

CITY

COUNTRY

NATIONALITY

TYPE OF DOCUMENT

Nº OF DOCUMENT

ISSUE DATE

EXPIRATION DATE

ISSUING AUTHORITY

Experiences in similar activities

YES
NO

If you answered "yes", specify where, when and max altitude. reached

Alergies

YES
NO

If you answered "yes", specify which ones

Chronic diseases (hypertension, diabetes, seizures, asthma, heart problems, blood problems, etc ...)

YES
NO

If you answered "yes", specify which ones

Use medications

YES
NO

If you answered "yes", specify which ones

Recent Surgery

YES
NO

If you answered "yes", specify how long ago and details of the surgery

Special diet

YES
NO

if you have any dietary restrictions; intolerance, allergy or some negative effect

Pregnant

YES
NO

Others

YES
NO

If yes, give more details

EMERGENCY CONTACT

PHONE

EMAIL *

COMPLETE ADRESS

INTERNATIONAL MEDICAL ASSISTANCE INSURANCE

I have a medical insurance contracted through TOLHUIN EXPEDITIONS AND LODGES
I have health insurance contracted through TOLHUIN EXPEDITIONS AND LODGES and COMPLEMENTARY INSURANCE
I do not have insurance contracted through TOLHUIN EXPEDITIONS AND LODGES, BUT I do have complementary insurance
I have NOT purchased insurance yet, but when I do, I will immediately send the pending information

COMPLEMENTARY INTERNATIONAL MEDICAL ASSISTANCE INSURANCE

Name of the provider company

Policy Number

Issue Date

Expiration date

Assistance phone

ACCEPTATION AND CONFIRMATION *

I DECLARE under oath or promise the veracity of the information provided and I assume under all responsibility any error or omission of the required information. In addition, I confirm that I have and promise to present all the original documents that are required in order to validate the information provided here.

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