Medical Information Form

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Mountaineering Patagonia - Chalten Freeride

In the interest and for the Safety of every participant and other members of the expedition, thank you for reading attentively before fulfilling this medical form

EXCURSION *

DATE *

YYYY

TRIP LEADER *

NAME & LAST NAME *

BIRTH DATE *

YYYY

PASSPORT N° *

NATIONALITY *

ADDRESS *

CITY *

STATE *

GENDER *

Male

Female

PHONE NUMBER *

EMAIL *

HEIGHT *

WEIGHT *

PROFESSION *

TRAVEL INSURANCE COMPANY *

Personal Insurance is your own responsibility.

We highly recommend you to travel with your own personal Insurance, we recommend:
https://ss.globalrescue.com/partner/mountaineeringpatagonia/

In case of emergency, please contact:

NAME AND LAST NAME *

PHONE *

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