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International Registration Form

Please complete this application for any trips taking place outside the United States or for our programs in Alaska. In order to process your application and schedule your trip, we must receive a complete application along with the appropriate deposit or final payment amount. Call the office at 509-548-5823 or send an e-mail to olivia@mountainschool.com with any questions.

Note: All information provided will be kept confidential and will not be transferred to 3rd parties
Fields with bold labels must be completed before your application can be processed

Program


Program Name:
Program Start Date:
Program End Date:

Your Information
Your Name:
Prefer to be Called:
Gender:	none
Address:
	,
Home Phone:
Cell Phone:
Work Phone:
Email Address:
Best Contact Method:	none
Date of Birth:
Occupation:
Marital Status:

Passport Information
Please send a legible photocopy of the first two pages of your passport. Please note many countries require your passport to be valid for at least 90 days beyond your scheduled return.
Passport Number:
Expiration Date:
Date and Place Issued:
Place of Birth:
Citizenship:

Emergency Contact Information
Contact Name:
Relationship to You:
Contact Address:
	,
Home Phone:
Cell Phone:
Work Phone:
Email Address:

Mountaineering or Skiing Experience
Please list your previous mountaineering or skiing experience, and any other activities related to this program (i.e. ski ability, hiking, etc.):

Training and Conditioning
<b>Please describe how you plan to prepare physically for this trip:</b>

Participant Medical Information
Please answer each question, providing detailed information on dates and type of medical treatment. Participation in any international climbing, trekking, or skiing program can be very strenuous and requires participants to be in good health. Many of our trips take place in areas where definitive medical care is unavailable. Our staff needs a very complete picture of your medical history in order to provide care should you be injured or become ill during your program. Your signature on this application indicates that the information you provide is true. Northwest Mountain School reserves the right to refuse service at the participant's expense due to misrepresentation of medical or background information.
List any major accidents, illnesses, or operations you have had in the past 5 years:
List any/all physical limitations or medical conditions that may restrict your ability to climb on this program:
List any/all medications (including dosages) you will be taking on this trip and why:
List any/all allergies to food and/or medication:
Are there any foods that you do not eat?
Have you ever had frostbite or a cold-related injury/illness? If yes, please elaborate:
Have you ever experienced any form of altitude illness?
Do you have any dietary restrictions?
Do you have back, knee, or other joint problems? If yes, please describe:
Do you wear glasses or corrective lenses?
What is your level of first-aid training?
Do you carry any medical insurance? If yes, indicate insurance Provider:
Is there any other information you feel our staff needs to have about your medical or physical condition?

Participant Information - Other Information
How did you hear about the Northwest Mountain School?

Insurance Information
Travel Insurance:	I have purchased Travel Insurance for this program
Travel Policy Info:
Rescue Insurance:	I have purchased Rescue Insurance for this Trip
Rescue Policy Info:

Accommodations and Meals
Single Occupancy:	I would prefer single occupancy
	Please note that there will generally be an additional fee for single occupancy. Also note that on some trips it may not be possible to fulfill requests for single occupancy.
Is there a person in the group you would like to be paired with?

Terms and Conditions
In order to register for any Northwest Mountain School program, you must read, understand and accept the following: NMS Terms and Conditions NMS Release Form Click the above links to read and print these documents.

Accepted:	By checking this box I confirm that I agree to the NMS Terms and Conditions and the Release of Liability and Assumption of Risk Agreement
Signature:	Dated:

International Registration Form

Northwest Mountain School