Hillary Outdoors Avalanche Awareness Application, Medical Form
Hillary Outdoors Education Centre - Tongariro
Which course would you like to book on? *
PARTICIPANT DETAILS
First and Last Names *
Your answer
Gender *
Age *
Your answer
Date of Birth *
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Phone 1 *
Your answer
Phone 2
Your answer
Address
Your answer
E-mail *
Your answer
Please tick the box if you do NOT want to receive information about other courses at Hillary Outdoors. At no time will we ever sell or provide your information to anyone else.
Please explain your experience in the mountains and relevant skills: *
Your answer
NEXT OF KIN / EMERGENCY CONTACT
Next of Kin Name *
Your answer
Relationship to participant *
Your answer
Phone 1 *
Your answer
Phone 2
Your answer
Email
Your answer
PERSONAL INFORMATION
Hillary Outdoors has a policy of inclusion. In order to achieve this safely it is vital that we have as much information as possible about our participants. It is ESSENTIAL that you give us accurate and detailed information. Note: Any information provided will be treated as confidential.

IF ANYTHING CHANGES BETWEEN COMPLETING THIS FORM AND THE TRIP IT IS ESSENTIAL YOU LET US KNOW.

Medical conditions (if required) e.g. injuries, allergies, anxiety, diabetes, obesity, behavioral, addiction, sight or hearing impediments etc
Your answer
Details of medication (if required) e.g. epipen, inhaler, antihistamine etc
Your answer
I agree to being given over the counter medication e.g. Panadol or ibuprofen *
CONSENT
Detailed information about our safety system and activities is provided at www.hillaryoutdoors.co.nz/safety/

IN SUMMARY:
- Hillary Outdoors offers a wide range of activities which may include: kayaking, canoeing, tubing, river walking, rock-climbing, ropes courses, abseiling, camping skiing, snowboarding and snow skills.
- Participation in all activities at Hillary Outdoors is voluntary although participants are supported and encouraged by their peers and instructor to participate to a level which challenges them.
- Because of the changeable and unpredictable nature of the outdoors risks can never be reduced to zero. Hazards exist in these activities that may result in serious injury or even death. These hazards include: weather / environmental conditions, height, water, equipment, Hillary Outdoors employees' behaviour and skills, client specific hazards, environmental impact and vehicles.
- Our goal is that no harm will occur whilst involved in activities. Our management strategies for achieving this can be viewed online.

PLEASE CONTACT US IF YOU REQUIRE MORE INFORMATION TO MAKE A DECISION, OR IF YOU HAVE ANY QUESTIONS

Please read each statement and then indicate your consent below.
- I understand there are risks associated with outdoor activities that cannot be reduced to zero. I know I am able to ask any questions of Hillary Outdoors or the individual instructor to gain a better understanding of the activity before deciding whether to take part, and the final decision about whether to take part or not is mine. If I decide to take part, I understand the instructor will identify any hazards that are liable to arise and correct procedures to deal with these, and that it is necessary for me to follow these. The instructor will take all reasonable precautions to ensure my safety. If I act outside of this advice, then I acknowledge I do so at my own risk and may be instructed to leave the programme or activity.

- I have received enough information to make an informed decision about the programme I am about to undertake.

- I authorise Hillary Outdoors to instigate medical assistance and treatment required in an emergency.

- I understand I may be charged for items belonging to Hillary Outdoors I lose or damage.

- I understand that my personal effects are not covered by Hillary Outdoors insurance policy.

- I understand that if I am under the influence of alcohol, drugs or other substances, Hillary Outdoors has the right to stop my further participation on the programme and I have no right for refund of my course fee.

- I have read the information sent to me and agree to act within Hillary Outdoors' policies and expectations. I understand that Hillary outdoors cannot be responsible for storage or administration of my child’s medication, unless specifically requested to do so prior to their visit.

- I understand that I need to pay in full at least 28 days prior to the start date to guarantee my place on the course.

- I understand there is a minimum number of participants required for the course to go ahead.

PLEASE CONTACT US IF YOU REQUIRE MORE INFORMATION TO MAKE A DECISION, OR IF YOU HAVE ANY QUESTIONS

I, the participant, agree with ALL of the above. *
We require all participants to complete this form. Photos and videos of participants to our courses may occasionally be used for marketing purposes. We assume your permission to use any of you unless otherwise requested by you.

By completing your name and the date below you are confirming that the information provided is as accurate and as complete as possible and you are confirming that your /your child's participation is in the stated Hillary Outdoors programme.

Participant's Name *
Your answer
Date *
MM
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PAYMENT
Course fee does not include a chairlift pass which may be purchased from Ruapehu Alpine Lifts. You may like to consider a Mt Ruapehu season pass if you are likely to visit the mountain a few times during the winter.
1 day Avalanche Course fee $185.
Credit Card Details - Number, Name & Expiry Date
Your answer
How did you hear about us? *
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