Toubkal Trek - Registration Form

Thank you for registering your interest in attending this expedition.

If you choose to go ahead, then we need to collect some important information from you in order to ensure your safety in Morocco.

The form below asks you to provide your contact details, passport details, next of kin, GP details, 1st aid training, previous travel experience, medical history and insurance details.

I’m sorry this is such a long questionnaire. The good news is that at the bottom of the form there is a “save and continue later” button, which you can click at any time. So, you don’t have to do it all at once.

After you complete the form, you will be redirected to a payments page, where you can also download some notes to help you prepare for the trek, including a packing list.

To secure your place in the team, please complete the form below:

Your Details
Name*

First

Last
Email*
Address and Postcode*
Preferred Telephone Number*
Date of Birth*

Date Format: MM slash DD slash YYYY
Passport Details
Full Passport Name*
Nationality*
Passport Number*
Place of Issue*
Date of Issue*
Date of Expiry*
Next of Kin Details
Name*
Relationship to You*
Home Phone*
Mobile*
Email*
GP Details
Name*

First

Last
Phone*
GP Address and Postcode*
Level of 1st Aid Training
Please indicate your level of 1st aid training*
Previous Travel Experience
Please provide a brief summary of your previous travel experience*
Medical History
Do you have any medical concerns that you would like to raise, in confidence, prior to the trip?*
If yes, you can either write your concerns below or leave it blank and we will contact you. Please feel free to approach us at any time independent of your response here with updated information or concerns.
Have you ever had lung/respiratory problems (e.g. asthma, COPD, pneumonia, TB, pulmonary embolism (PE), lung surgery)?
If yes, please provide details here:
Have you ever had heart/cardiac/blood vessel problems (e.g. high blood pressure, angina, heart attack, deep vein thrombosis (DVT), heart surgery)?*
If yes, please provide details here:
Have you ever had abdominal/bowel problems (e.g. hernias, stomach ulcers, reflux, inflammatory bowel disease, abdominal surgery, constipation, diarrhoea)?*
If yes, please provide details here:
Have you ever had brain/nerve problems (e.g. epilepsy, seizure, severe headaches, migraines, sciatica, carpel tunnel syndrome, reduced sensation, brain surgery)?*
If yes, please provide details here:
Have you ever had kidney/urinary/liver problems (e.g. recurrent cystitis, renal failure, liver failure, jaundice, hepatitis, pyelonephritis)?*
If yes, please provide details here:
Have you ever had hormone/endocrine problems (e.g. diabetes, thyroid problems)?*
If yes, please provide details here:
Have you ever had psychiatric/psychological problems (e.g. depression, schizophrenia, bipolar disorder, psychosis, overdose, self-harm, eating disorder)?*
If yes, please provide details here:
Have you ever had altitude problems (e.g. acute mountain sickness (AMS), high altitude cerebral oedema (HACE), high altitude pulmonary oedema (HAPE))?*
If yes, please provide details here:
Have you ever had cold related problems (e.g. frostbite, Raynaud’s syndrome/very cold hands and feet, cold- induced asthma, chilblains, immersion/trench foot, hypothermia)?*
If yes, please provide details here:
Have you ever had heat related problems (e.g. heat exhaustion, heat stroke, sun stroke)?*
If yes, please provide details here:
Are you currently seeking specialist advice or treatment for any medical conditions?*
If yes, please provide details here:
Have you ever suffered from a medical condition that you have not mentioned above requiring admission to hospital, long-term treatment or surgery?*
If yes, please provide details here:
Have you had a dental check-up in the last year?*
Do you have any ongoing dental problems?*
If yes, please provide details here:
What is your Blood Group (if known)*
Have you ever had a blood transfusion?*
If yes, please provide details here:
Do you have any form of physical or mental impairment or disability not mentioned above?*
If yes, please provide details here:
Are you currently taking any medications regularly (please including oral contraceptive, over-the-counter medications, inhalers, creams and herbal remedies*)?*
If yes, please list the medication's name, dose and how often it is taken
Have you ever had an allergic reaction to any medication?*
If ‘Yes’, please list the medication’s name and describe the symptoms/treatment of the reaction:
Have you ever had an allergic reaction to foods or environmental triggers (e.g. cats)?*
If yes, please provide details here:
Do you suffer from vertigo / fear of heights / motion sickness?*
If yes, please provide details here:
Do you have any special dietary needs?*
If yes, please provide details here:
Do you wear contact lenses?*
Are you pregnant or might be at the time of travel?*
Are you a smoker*
Please rate your physical condition*
Insurance Details
Insurance must include helicopter evacuation*
- My insurance includes helicopter evacuation
Name of Insurer*
(I recommend Cambell Irvine, n.b. Morocco = Europe)
Policy Number*
Medical emergency contact number for your insurance policy*
Payment
The total fee for this trip (not including flights) is £745.

Once the form is submitted you will be redirected to a payments page
Declaration
Personal Statement*
I agree that the above information is true and accurate to the best of my knowledge.
As far as I am aware I am medically fit to partake in a remote expedition which will be both physically and mentally demanding and potentially include exposure to extremes of heat, cold and altitude.
I understand that I am responsible for providing all my normal medications and supplies for the treatment of my pre-existing medical conditions for the duration of the expedition.
I understand that my medical information will be kept confidential and every effort will be made to consult me beforehand should any disclosures be deemed necessary.
I agree that should I become incapable of giving consent for disclosure of essential medical information in the event of an emergency, information may be imparted at the discretion of the medical team acting in my best interests.
On return from the expedition, I consent to my GP being contacted with details of any serious illness or accident arising during the expedition.
I agree to discuss/disclose to the organisers any injury or illness occurring between this date and the date of departure.
- By checking this box, I confirm the above statements to be true

Save and Continue Later

Toubkal Trek – Registration Form

Your Details

Passport Details

Next of Kin Details

GP Details

Level of 1st Aid Training

Previous Travel Experience

Medical History

Insurance Details

Payment

Declaration