Last Name *
Birth date (MM/DD/YYYY) *
Document Type and Number *
Address: Street and number *
Province / State *
Name of the trip that you will make
Starting date of the trip *
Arrival Date and Time
Flight coming from
Departure Date and Time
Emergency Contact Name
Email of contact
Type of insurance
Do you have any of the following conditions?
High blood pressure
Type of high blood pressure controlled with medicinecontrolled without medicinenot controlled
Breathing problems, asthma, etc
Are you taking any medicine?
Where and when?
Do you wear glasses?
Acute Mountain Sickness
Pulmonary edema in high altitude
Altitude and Date
Cerebral Edema in high altitude
Altidude and Date
Where and what grade?
General health? Very goodGoodRegularBad
Altitude surpassed climbing in mountains
Any other condition that affects your health?
Do you have any food restrictions, are you a vegetarian?
Do you need to rent any personal mountain gear?
I declare that the information provided is correct. *
4 + 3 = ? Please prove that you are human by solving the equation *