WildMedix Kilimanjaro Mountain Medicine Expedition 2018 - Preregistration
Introduction:
Please fill in this form if you are interested in attending the WildMedix Kilimanjaro Mountain Medicine Expedition in September 2018. Completion of the form does not bind you to participation in the expedition, nor does it guarantee you a place, but we will allocate places on a first-come first-served basis if the number of participants exceeds our limit. Please give us the most honest and accurate information that you can.

Accreditation:
The mini-expedition is eligible for WMS FAWM credits.

Venue & dates:
Kilimanjaro, Tanzania
8 - 20 Sept 2018 (exact dates might shift to either side a tiny bit)

Costs:
The provisional cost for the 2018 Kilimanjaro Mountain Medicine Expedition is USD 4950.
The expedition fee includes transfers to and from Kilimanjaro International Airport, lodge and hotel accommodation on a shared basis before and after entering the park, Kilimanjaro National Park entrance, trekking and rescue fees, temporary membership of the AMREF flying doctor service, all training, professional mountain leadership, local guide, porter and cook fees, all meals and clean water from the first evening until the last morning, tented accommodation on the mountain with camping mattresses, group equipment, prescribed wilderness medicine and navigation textbooks for each participant (sent to you before the expedition), a certificate and badge on successful completion, commemorative headgear, a summit certificate, and WMS FAWM accreditation. A single supplement is available for the lodge/hotel, but not on the mountain for safety reasons.  

Flights to Tanzania, drinks, porter/guide tips, your own medical and travel insurance and personal equipment are NOT included. A discounted fee is available to WMS members and returning WildMedix customers. Group size is limited to guarantee personal and focussed attention on all participants.

The trek-only option expedition fee is USD 4100, and includes all items except the textbooks, lectures and practical/simulation exercises, and course completion certificate.  


If you have queries, please contact gela@wildmedix.com or ross@wildmedix.com.
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Name and surname *
Calling name/nickname
What should we call you?
Returning customer? *
Gender *
Age *
(On September 11, 2018)
Date of birth *
MM
/
DD
/
YYYY
Contact information and next-of-kin details
We need these details to keep in touch with you. By completing the form, you give us permission to send you further information. At any stage, if you don't want to be included, just let us know and we will delete you from the list. We don't give your info to anyone else.
Email address *
Mobile telephone *
Please include international dialing code
Mailing address *
Where we may send your books if you pay the deposit
Next-of-kin name *
Next-of-kin relationship *
Next-of-kin telephone number *
I understand that I must have personal travel and medical insurance for this expedition *
Your expedition fee does include temporary membership of the AMREF flying doctor service, but you should carry your own travel and medical insurance in addition. Please make sure that you are covered for trekking and/or mountaineering at high altitude. There is no technical climbing involved in the expedition. Many insurers have a specific category for Kilimanjaro.
Travel insurance company *
Medical & Physical Information
This might feel a little personal...and it is. Please understand that we have a responsibility to look after you on the expedition, as you may one day as an expedition medic. Your honest answers keep us all safe, and are not likely to exclude you from participation. Your answers are protected by doctor-patient confidentiality.

Are you physically fit enough to hike over varied terrain carrying a small backpack at a moderate pace for an entire day, or do you commit to being fit enough by September 10, 2018? *
Disabilities *
Allergies *
Blood type (ABO) *
Blood type (Rhesus) *
Height (cm) *
1 inch = 2.54 cm
Body weight (kg) *
1 kg = 2.2 lb
Medical conditions *
Please list any chronic or occasional conditions here.
Chronic or regular medications *
Please list any medications you may require on the expedition here.  Please plan to bring these items with you.
Medical Qualifications
This expedition is aimed at medical practitioners (or at a minimum, well trained volunteers, eg. with SAR teams). It helps us to tailor the content if we understand your background.
Medical practitioner type *
Please tick all that apply
Required
Formal medical qualifications *
Please tick all that apply
Required
Fields of expertise *
Fields in which you hold qualifications or significant experience
Required
HPCSA number (if applicable):
Are you a current member of the WMS? *
Are you a FAWM candidate? *
What is your normal (medical) job? *
Describe what your role is at work so we understand your perspective.  If you're coming for the trek only, what do you do between weekends?
Expedition Experience
No experience is required, but this helps us to tailor your learning and may inspire us to ask you to contribute.
Have you partaken in other wilderness expeditions? *
An expedition is a back-country trip into a wilderness area without physical infrastructure for a minimum of 3 days
Quantifying your expedition experience
What expeditions have you undertaken? *
Give a quick summary
What roles (if any) did you serve on previous expeditions? *
(Eg. leader, doctor, participant, etc)
Mountaineering Experience
No experience is required, but this helps us to tailor your learning and may inspire us to ask you to contribute.
Do you have previous mountaineering experience? *
Mountain and/or rock climbing where ropes are required or desirable
Quantifying your mountaineering experience
Give us an idea of the types of mountaineering you have done and how you judge your experience: *
What is the highest altitude you have hiked/climbed to? *
Please specify meters or feet!
What place/peak was your highest ascent? *
Have you suffered from altitude related illnesses in the past? *
Willingness to participate in research
Yip, we are all guinea-pigs in the great experiment called life ;)
Would you be interested in taking part in research on the expedition? *
Anything else?
What would you like to know or tell us?
What *I* want to know is...
I think *you* need to know...
Waiver
Download the medical particulars and waiver form: https://drive.google.com/open?id=0BwKze-JaZFKSMTNTVTZIR1VCVGM

Complete the form, and email it to: gela@wildmedix.com.
Note that participation in the course is only permitted once the completed form and signed waiver have been received.

Important policies and procedures to take note of:
RESERVATIONS & BOOKING PROCEDURE
Reservations are done electronically by means of an online registration form. Once the submission has been checked and space for the indicated course has been verified, an email will be sent to confirm the booking.

PAYMENT POLICY - MINI-EXPEDITIONS AND EXPEDITIONS
DEPOSIT: If a booking is confirmed 60 days or longer before course commencement, a 50% non-refundable deposit is payable to secure the booking.
BALANCE of payment is due a minimum of 60 days before the start of the course. If the balance is not paid 60 days before the course, Wild Medix may deem the booking void and rebook the vacancy. If a booking is confirmed less than 60 days in advance, the full price is payable.

CANCELLATION POLICY & PROCEDURE - MINI-EXPEDITIONS AND EXPEDITIONS
CANCELLATIONS can be made telephonically and confirmed in writing, or just in writing.
POLICY: If a cancellation is made more than 60 days in advance, only the deposit will be forfeited. A cancellation made less than 60 days in advance will forfeit the full fare.  
These policies and procedures are in line with international industry practices.
CANCELLATION BY WILD MEDIX: Should a mini-expedition or expedition be cancelled by Wild Medix before its scheduled commencement, the full fare will either be refunded or a substitute date offered. In the event of Wild Medix cancelling a course we accept no responsibility for any additional costs incurred by the client related to the cancelled course.

OTHER
PERSONAL HEALTH: It is the client’s responsibility to inform the instructor of any (pre)existing or chronical medical or health problems.
WEATHER & CLIMATE CONDITIONS can change without warning from extremely hot to freezing cold. Come prepared for all eventualities and have adequate sun protection.
INSURANCE: Comprehensive travel insurance covering cancellation, curtailment, medical, emergency travel and personal accident is compulsory for long courses. It is the participant’s responsibility to ensure that his/her insurance is adequate and fully covers their personal needs.
COMPLAINTS during the course should be brought to the attention of the course facilitator(s) immediately in order to allow the matter to be rectified soonest. Complaints after the course should be made in writing within 30 days after the end of the course.
I have read and understood the above, and herewith agree to the above policies and procedures: *
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