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          Reservations - Booking Form  
 
   

Please, fill one booking form for each expedition member. Complete all the information required. Thank you.

a) Personal Information
Name:
 
Gender:
 
Date of Birth:
 

(mm/dd/aaaa)

Nacionality:
 
Passport Number :
 
Address:
 
Telephone Number:
  (please add country and city code)
E-mail Address:
 
Profession:
 

b) Contact Information in Case of Emergency
Contact #1
   
Name:
 
Telephone:
  (please add country and city code)
E-mai Address:
 
Contact #2
   
Name:
 
Telephone:
  (please add country and city code)
E-mai Address:
 

c) Medical Information 
1. How tall are you? How much do you weigh?
 
2. Blood Type:  
3. Are you undergoing any medical treatment? If the answer is yes, please expand on it.
 
4. Do you take any medicine on a regular basis? Please be specific.
 
5. Have you ever suffered from Cerebral or Lung Edema?
 
6. Do you suffer from any special condition on your knees, back or chest?
 
7. Have you ever had any problem related to altitude in any of your previous experiences?
 
8. Do you suffer from any physical problem we should know?  
9. If woman, are you pregnant?  
10. Do you smoke? If the answer is yes, please specify how often you smoke and how many cigarettes.  
11. Do you have any regular fitness program? What kind of activity?  
12. Allergies?:
 
13. Have you ever suffered from any of the following conditions: asthma, diabetes, heart disease, epilepsy or any other condition we should be informed about?  

d) Food Information
Are you Vegetarian?:
  (extra cost applied for vegetarian food)
Do you have any food restriction?:
 

e) Expedition Information
Type of expedition:
 
Do you want to take the Extended Acclimatization Program (PAE)?
 
Departure date of expedition:
 
Arrival date to Mendoza:
 
Airline and flight number:
 
Departure date of Mendoza:
 
Airline and flight number:
 

f) Aditional Information
Please write a resume of your mountain experience:
 
Any other comments:
 
How did you know about our company?
 

g) Terms and Conditions of Service
   
Once you submit your Booking Form it is considered a sworn statement (affidavit) and Aconcagua Expeditions.com understands that you have analyzed, understand and accept all of the Terms and Conditions of Service detailed in this form.
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