open enrollment - Earth Treks Climbing Centers

open enrollment - Earth Treks Climbing Centers
ECUADOR EXPEDITION APPLICATION
OPEN ENROLLMENT
MOUNTAINEERING EXPEDITIONS
GENERAL INFORMATION
Please complete this application and mail it to Earth Treks Climbing Expeditions, LLC with your $500 deposit.
Expedition Name: Expedition Dates: Name (as it appears on your passport):
Street Address: City: State: Zip:
Phone (Home): (Work): (Cell): Email Address:
How did you learn about Earth Treks? Briefly describe your traveling experience: Briefly describe your personal climbing experience (previous climbing experience is not a prerequisite for many of our courses):
Briefly describe your outdoor experience: As a climber, what goals would you like to achieve, and how can Earth Treks Climbing Expeditions help you achieve them? Briefly describe your current level of physical fitness and fitness regime: PERSONAL INFORMATION:
Date of Birth: Marital Status: Gender:
Male
Female
Passport Number: Occupation:
Place of Issue: Citizenship:
Date of Issue: Birthplace:
IN CASE OF EMERGENCY:
In case of emergency, please notify:
Relationship: Street Address: City: State: Zip: Phone (Home): (Work): (Cell): TRAVEL INFORMATION: (update ETCE as details become available):
Name of airline you will be arriving on:Arrival Flight Number:
Arrival date and time:Departure date and time:
I prefer a single room at a supplemental cost:
Yes
No
Boots for Mountain & Ice Climbing Trips: Boot Size: Gender:
Male
Female
ROCK CLIMBING INSTRUCTION • MOUNTAINEERING GUIDE SERVICE • INDOOR CLIMBING CENTERS
7125 C COLUMBIA GATEWAY DRIVE • COLUMBIA, MD 21046 • 800-CLIMB-UP • EXPEDITIONS@EARTHTREKSCLIMBING.COM
1
ECUADOR EXPEDITION APPLICATION
OPEN ENROLLMENT
MOUNTAINEERING EXPEDITIONS
TERMS & CONDITIONS
What is included in the cost of a trip: Prices given are for land costs only. This includes double occupancy lodging in hotels,
meals on the mountain/trek, scheduled bus/auto/air transportation within the countries we are visiting, guides, group climbing
and cooking gear (kitchen supplies, tents, ropes, etc.), porters and pack animals where applicable.
What is not included in the cost of the trip: Airfare to and from city where expedition begins, airport taxes, personal climbing
permit, personal porters (optional), small group supplements, meals in destination cities, hospitalization or evacuation from
remote areas, medical check-ups, immunizations, insurance of any kind, excess baggage charges, additional lodging charges
for those desiring a single room, laundry services or other personal expenses, liquor, snacks, souvenirs, and tips for guides and
camp staff.
The cost of delays is not included if any trip is held up due to river levels, road and trail conditions, flight delays, illness, government
delays or any other factor which is beyond the control of Earth Treks Climbing Expeditions, LLC (ETCE) or their agents.
Payment and Application Policy: A completed application and a $500 deposit is required to confirm enrollment. The balance
of the trip cost is due 60 days before departure. We accept cash, checks and money orders. Unfortunately, we do not accept
credit cards for mountaineering trip payments. Please mail your payments and application to:
Earth Treks Climbing Expeditions, LLC. 7125 C Columbia Gateway Dr. Columbia MD 21046 USA.
You may also contact us by phone, Monday through Friday from 9 am to 5 pm EST at 410-872-0060, ext. 117.
We reserve the right to cancel any trip due to inadequate sign up, natural disasters, or political unrest. We will fully refund the
land costs in that case. If you must cancel your trip 90 days or more prior to departure all payments will be refunded. If you
must cancel your trip more than 60 days prior to departure and less than 90, your payments will be refunded, minus the $500
deposit. If we are notified 60 days or less before the trip, there will be no refunds.
Once on the trip, ETCE reserves the right to remove any person from the trip who, at the sole discretion of the guides, is
judged to be a safety risk to themselves or others. This includes those persons who are not acclimatizing adequately or are not
strong or skilled enough to safely climb. In this case, there will be no refunds.
Itinerary: ETCE reserves the right to determine routes and destinations and to change these at the discretion of the guides in
order to best meet the needs of the participants and to ensure maximum safety. No refunds will be given in the event of a
change in the course itinerary.
Insurance: We strongly suggest that all participants purchase an International Travel Insurance Policy that covers emergency
evacuation and medical emergencies. Insure that the policy does not exclude high altitude mountaineering. Many insurance
companies require that you obtain your policy soon after you book any travel arrangements, so please do not delay. We strongly
recommend that you additionally obtain coverage for trip cancellation and lost luggage. Various travel insurance policies will
cover these expenses to differing degrees. One option is TravelGuard.com. From their product list choose the customizable “My
Travel Guard” product and be sure to elect the optional Adventure Sports Upgrade. Please be sure to read ALL the fine print.
Medical Care: This trip is a rigorous mountain climbing expedition. By its very nature it is physically demanding and involves
travel to many areas where medical facilities are virtually nonexistent. ETCE assumes no liability regarding the provision of
medical care. You are urged to check your insurance coverage to be sure it is adequate. The trip leaders have the right to
disqualify any member from the group at any time if considered medically necessary or to avoid endangering the group, or if the
participant in question is physically unfit for the rigors of the trip. Refunds are not given under such circumstances.
Applicant Name (please print):
Applicant Signature:
Date:
ROCK CLIMBING INSTRUCTION • MOUNTAINEERING GUIDE SERVICE • INDOOR CLIMBING CENTERS
7125 C COLUMBIA GATEWAY DRIVE • COLUMBIA, MD 21046 • 800-CLIMB-UP • EXPEDITIONS@EARTHTREKSCLIMBING.COM
2
ECUADOR EXPEDITION APPLICATION
OPEN ENROLLMENT
MOUNTAINEERING EXPEDITIONS
MEDICAL INFORMATION
Earth Treks, Inc. strongly recommends that you see your doctor, discuss the rigors of the trip with him/her, and receive a thorough physical.
INSURANCE: You are responsible for any medical expenses and should be covered by your own health insurance (details to be
completed below). In addition, we strongly suggest that all participants purchase an International Travel Insurance Policy that
covers emergency evacuation and medical emergencies (as detailed in Terms and Conditions).
Are you covered by hospitalization and medical care insurance? Yes
No
Policy or Certificate Number:
Insurance Company: Phone #:
Address:
GENERAL MEDICAL INFORMATION:
Height: Weight: General fitness:  EXCELLENT
 GOOD  FAIR
Blood Pressure: /
Pulse Rate: Date Taken: Dietary Restrictions:  None  Vegetarian  Other (please describe) _____________________________________________
CHRONIC HEALTH PROBLEMS: If you have any health problems of which we should be aware of, please check below and describe.
Musculoskeletal pain or injury (neck, back, knee, hip, shoulder, etc): Diabetes, seizures, or frequent or unexplained fainting or dizziness: Do you suffer from any long term health issues? If so, please provide details: Are you taking any medications (OTC or prescription)? If so, please provide details including intended treatment: Have you been hospitalized or sought medical help for any injury, illness or other medical condition in the last 5 years? If
so, please provide details, including any long term medical issues surrounding this treatment. Have you experienced any cold weather or altitude related injuries/illness such as frostbite or hypothermia? List any and all allergies to food, medication and/or environmental conditions: Date of last tetanus shot:
Immunizations you are receiving for this trip:
Consent is hereby given to attend an Earth Treks Climbing Expeditions, LLC (ETCE) trip and permission is given for emergency anesthesia, operation,
hospitalization or other treatment which might become necessary. The information provided above is a complete and accurate statement of the
physical factors which may affect my participation on an ETCE trip. I realize that failure to disclose such information could result in harm to myself
and my fellow participants, and I agree to indemnify and hold harmless ETCE if all relevant information is not disclosed. I also agree to notify ETCE
should there be any change in my health prior to the course. ETCE reserves the right to turn down applications based on health or fitness.
Date:Applicant Name (please print):
Applicant Signature:
Signature of parent or legal guardian if applicant is under the age of 18: ROCK CLIMBING INSTRUCTION • MOUNTAINEERING GUIDE SERVICE • INDOOR CLIMBING CENTERS
7125 C COLUMBIA GATEWAY DRIVE • COLUMBIA, MD 21046 • 800-CLIMB-UP • EXPEDITIONS@EARTHTREKSCLIMBING.COM
ECUADOR EXPEDITION APPLICATION
OPEN ENROLLMENT
MOUNTAINEERING EXPEDITIONS
RELEASE OF LIABILITY
The individual named below desires : (a) to use or permit the use of one or more of the Earth Treks Climbing Centers (individually or collectively as the
context may require, “Facility”) located at- - (i) 7125 --C Columbia Gateway Drive, Columbia, Maryland 21046, 725Rockville Pike, Rockville, Maryland
20852, and/or 1930 Greenspring Drive, Timonium, Maryland 21093 (collectively, “Maryland Facilities”), and/or (ii) 700 Golden Ridge Road, Golden,
Colorado 80401 (“Colorado Facility”); and/or (b) to participate in trips and/or climbing expeditions sponsored by or involving the following (individually or
collectively as the context may require, “Earth Treks”) - - (i) Earth Treks, Inc., Earth Treks Columbia Climbing Center, LLC, Earth Treks Timonium Climbing
Center, LLC, Earth Treks Rockville Climbing Center, LLC, and/or Earth Treks Climbing Expeditions, LLC (collectively, “Maryland Entities”), and/or (ii) Earth
Treks Golden LLC and/or Earth Treks Golden Climbing Center, LLC (collectively,“ Colorado Entities”). In consideration for Earth Treks permitting me to
use the Facility and permitting me to participate in the trips and/or climbing expeditions (“Trips”), I have agreed to execute thisWaiver And Release Of
Liability And Assumption Of Risks (“Release”).
WARNING BY EARTH TREKS : There are significant elements of risk associated with climbing and any adventure, sport or activity associated
with Earth Treks (individually, “Activity” and collectively, “Activities”). Although Earth Treks has taken reasonable steps to provide you with appropriate
equipment and/or skilled instructors so you can enjoy each particular Activity for which you may or may not be skilled, we must remind you that each
Activity is not without risk. Certain risks cannot be eliminated without destroying the unique character of the Activity. The same elements that contribute
to the unique character of the Activity can be causes of accidental injury, illness, or in extreme cases, permanent trauma or death.
I acknowledge that using the Facility, participating in the Trips and participating in other Activities sponsored by Earth Treks involves certain inherent
risks, including the risk of death or serious personal injury. I agree to assume all such risks, as well as any other risks involved in using the Facility,
participating in the Trips or participating in any other Activity sponsored by or involving Earth Treks. I agree to release and discharge Earth Treks and all
of its officers, directors, managers, members, employees, agents, and representatives, as well as all other persons or entities that may own, operate or
manage each Facility, including but not limited to the respective landlord of each Facility, as well as any and all other persons or entities that might have
any liability whatsoever to me (collectively,“ Released Parties”),from and against any and all damages, actions, claims and liabilities, whether known
or unknown, anticipated or unanticipated, suspected or unsuspected, relating to or arising from any A ctivity, occurrence or event involving the Facility,
the Trips or Earth Treks. This Release is intended to release and discharge the Released Parties from all damages, actions, claims and liabilities of any
nature, specifically including, but not limited to, damages, actions, claims and liabilities arising from or related to the negligence of the Released Parties.
I further agree to indemnify, hold harmless and defend Earth Treks and each of the other Released Parties from and against any loss, damage, liability and
expense, including costs and attorneys’ fees, incurred by Earth Treks or any of the other Released Parties as a result of my using the Facility, participating
in the Trips, or participating in any other Activity sponsored by or involving Earth Treks. In addition, I understand that wearing a helmet while climbing at
the Facility or participating in a Trip is recommended. If I choose not to wear a helmet, I agree to assume all risk of personal injury and death that may
occur as a result of not wearing a helmet.
Insofar as the Maryland Facilities and the Maryland Entities are concerned: (a) the laws of the State of Maryland shall govern the rights and
obligations of the parties to this Release and the interpretation, construction and enforceability thereof; and (b)I agree that any lawsuit brought against
any Released Parties shall be brought solely in the Circuit Courts for Howard County, Baltimore County or Montgomery County, Maryland.Insofar as the
Colorado Facility and the Colorado Entities are concerned: (i) the laws of the State of Colorado shall govern the rights and obligations of the parties to
this Release and the interpretation, construction and enforceability thereof; and (ii) I agree that any lawsuit brought against any Released Parties shall
be brought solely in the District Court for the First Judicial District, Jefferson County, Colorado. This Release shall be effective upon my execution hereof
and shall continue in force, unless sooner terminated pursuant to a written notice, for so long as I or (if applicable) my child or such other below-named
individual use a Facility, participate in a Trip, or participate in any otherActivity sponsored by or involving Earth Treks.
I acknowledge and agree that Earth Treks reserves the right to use any photograph taken at the Facility, on a Trip, or in connection with any other
Activity involving Earth Treks to be used in Earth Treks’ promotional materials, brochures and website.
I HAVE READ AND UNDERSTAND THE FOREGOING ACKNOWLEDGMENT OF RISK, ASSUMPTION OF RISK AND RESPONSIBILITY, AND RELEASE OF
LIABILITY. I UNDERSTAND THAT BY SIGNING THIS FORM I MAY BE WAIVING VALUABLE LEGAL RIGHTS
THIS RELEASE IS A BINDING LEGAL CONTRACT. PLEASE READ IT CAREFULLY BEFORE SIGNING **Please print legibily.**
Please print all of the required information legibly.
Applicant Name (please print):Date:
Applicant Signature:
Date of Birth:
ROCK CLIMBING INSTRUCTION • MOUNTAINEERING GUIDE SERVICE • INDOOR CLIMBING CENTERS
7125 C COLUMBIA GATEWAY DRIVE • COLUMBIA, MD 21046 • 800-CLIMB-UP • EXPEDITIONS@EARTHTREKSCLIMBING.COM
4
ECUADOR EXPEDITION APPLICATION
OPEN ENROLLMENT
MOUNTAINEERING EXPEDITIONS
GENERAL INFORMATION
MEDICAL & FITNESS
GENERAL PRECAUTIONS & SUGGESTIONS
•This trip is a rigorous mountain climbing expedition. By its very nature it is physically demanding and involves travel
to many areas where medical facilities are virtually nonexistent. EARTH TREKS CLIMBING EXPEDITIONS, LLC (ETCE).
assumes no liability regarding the provision of medical care.
•You are urged to check your insurance coverage to be sure it is adequate. The trip leaders have the right to disqualify
any member from the group at any time if considered medically necessary or to avoid endangering the group, or if the
participant in question is physically unfit for the rigors of the trip. Refunds are not given under such circumstances.
•You should have a personal supply of any special medications which you may need. It is understood that ETCE is not
a medical facility and therefore has neither expertise nor responsibility regarding what medications or inoculations you
and your private physician should decide necessary for your safe participation in the tour.
•In addition, we strongly recommend visiting a travel clinic in your area. Travel clinics can be more knowledgeable than
your primary care physician on the vaccinations and prescriptions needed for our trips. (e.g. Passport Health www.
passporthealthusa.com or 888-499-7277).
•The fitter you are aerobically, the more fun you will be able to have. It is a medically proven physiological fact that
life above 10,000 ft. will put a strain on a human body. Some of us may suffer from fatigue due to our not properly
preparing our bodies. At the very least, please exercise aerobically for an hour at least four times a week. Running and
biking are highly recommended forms of exercise for high altitude mountaineering. Combine these regular workouts
with a few long day-hikes with a small pack on the biggest hills you can find in your area. Please consult and adhere
to the suggested Mountain Training Guide in order to increase your chances for success on your expedition!
MEDICATIONS
•Many climbers who take part in extended high altitude mountaineering trips, take Diamox (Acetazolamide)
prophylactically. Our experience has shown that Diamox’s proven ability to aid in the prevention of altitude related
illnesses has increased the ability for team members to have and easier acclimatization and greater chance of success.
Diamox is most easily used in 250mg or 500 mg time release capsules (preferred). Be sure to ask your physician to
order your prescription for you to take a 500mg/day dosage for your entire trip..
•Many travelers visiting developing nations carry a course of Ciprofloxacin (Cipro) (500 mg tablets). Cipro is a powerful
broad-based antibiotic that fights gastrointestinal problems which, if left untreated, might force you to change your
schedule or an early cancellation of your expedition. Please ask your doctor about the use of this drug.
•Malaria is not a threat in the highlands where we operate most of our expeditions. If joining a Kilimanjaro Expedition,
please consult your doctor on the need for antimalarials and other inoculations for the safari.
•Women may find that taking prenatal vitamins (because these vitamins are high in iron content) for 30 days prior to
an expedition will aid their body’s response to high altitude.
•If you are prone to motion sickness, bring along Dramamine or similar medication. The long bus rides can be tough
on weak stomachs.
ROCK CLIMBING INSTRUCTION • MOUNTAINEERING GUIDE SERVICE • INDOOR CLIMBING CENTERS
7125 C COLUMBIA GATEWAY DRIVE • COLUMBIA, MD 21046 • 800-CLIMB-UP • EXPEDITIONS@EARTHTREKSCLIMBING.COM
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ECUADOR EXPEDITION APPLICATION
OPEN ENROLLMENT
MOUNTAINEERING EXPEDITIONS
GENERAL INFORMATION (continued)
•The sun is extremely intense at the altitudes we visit. We are in the rarefied air of the upper elevations. Invest in a
really good pair of glacier glasses, powerful sunscreen (SPF 40 or better and zinc oxide if you are especially sensitive to
the sun), and a baseball or sun hat/visor.
INTESTINAL ISSUES
•Diarrhea is a common ailment in the nations we visit. Basically, new strains of bacteria visit our intestines during these trips
and our body has only one way to get rid of them. As noted earlier, ask your doctor about Cipro
•Also stock up on maximal strength Pepto Bismol (mild diarrhea) Imodium AD (severe diarrhea) and TUMS (stomach).
•In order to avoid dehydration, you’ll need to drink plenty of liquids during the expedition..
•Remember that prevention is the best medicine. Try to avoid drinking water that wasn’t either filtered, boiled or iodized.
Never swap water bottles. Don’t eat fruits and vegetables that are not peeled or washed in treated water. We’ll only dine in
places that cater to the stomachs of gringo westerners.
•If you do get diarrhea, please let your guide know so that we can supply you with a little compassion and the best medical
treatment available.
•It is always advisable to carry a stash of toilet paper & hand sanitizer with you, as not all rest rooms are stocked.
MONEY (Expenses, gifts and tips).
Meals not covered by the expedition. Plan on spending $5-$10 per breakfast and lunch and $10 to $20 per dinner while in
town. Carry your money and passport in a neck pouch or waist belt. Look for these at your local camping store.
Gifts: People love presents. If you have a lover, a big family or an irate boss, you had better bring a duffel bag full of $20 dollar
bills. There are local markets we can visit on our expedition for handcrafted souvenirs, jewelry and artwork. Bargaining is the
name of the game, so feel free to haggle with the locals.
Tips: Most of our expeditions are accompanied by local guides, porters, cooks, and burro/horse drivers. Tipping of these staff is
customary. Ask your guide for suggested amounts. Tipping your western gringo guide is always appreciated.
PERSONAL SAFETY
•Theft is a possibility. Thieves will be looking for luggage that is easily opened and expensive looking. Heavy nylon duffels
are a good best bet for luggage. Get a small lock to secure it all. If flying from a location which does not allow locked
luggage, zip tie the zipper shut. If TSA cuts a zip tie off your bag, they will replace it with a new one.
•Handbags are easily snatched, or sliced by a razor; think twice about bringing one.
•Leave expensive looking jewelry at home.
•Keep your daypack either in your lap, or with a strap around the leg of the chair you’re sitting in.
•Don’t keep much money or your identification in your pants pocket. Rather wear a neck pouch or money belt to discourage
pick pockets.
•Cell phones are an easy target for thieves in urban areas. We’ve experienced several being stolen in the last several years,
so vigilance is your best bet against theft.
ROCK CLIMBING INSTRUCTION • MOUNTAINEERING GUIDE SERVICE • INDOOR CLIMBING CENTERS
7125 C COLUMBIA GATEWAY DRIVE • COLUMBIA, MD 21046 • 800-CLIMB-UP • EXPEDITIONS@EARTHTREKSCLIMBING.COM
6
ECUADOR EXPEDITION APPLICATION
OPEN ENROLLMENT
MOUNTAINEERING EXPEDITIONS
GENERAL INFORMATION (continued)
•Before you leave home write down your passport number, traveler’s check numbers, plane ticket number and any
other vital info and Xerox a few copies of the list. Scatter these lists throughout your luggage.
•Carry-on: Everything should fit into a single daypack (jackets, cameras, books, everything). We suggest that you
bring the following critical items (in case your checked bags do not arrive):
•Boots (& 1-2 pair of warm socks)
•Rainwear - tops & bottom
•Prescription medications. (NOTE Start taking your first diamox the first day of travel. Be sure to have your
pharmacy give you 10-12 days worth of pills for Cotopaxi only. More for extended trips).
•Headlamp
•Sunglasses.
EMERGENCY CONTACT INFORMATION
In the case of an emergency at home while you are on your trip, family can contact Chris Jenkins at the Earth Treks office:
410-872-0060 or 800-254-6287, cj@earthtreksclimbing.com. If it is after hours, please call Chris Jenkins @ 443-7452119. They will get in touch with us as quickly as possible. This is also your best route to get in touch with us if you miss a
flight or are somehow delayed on your way to your expedition. They will be able to let us know of your situation, along with
your new arrival information.
THE ADVENTURE BEGINS... Once you are on the plane and headed to the expedition, it will be an adventure filled with
lots of opportunities to interact with local cultures, be part of a dynamic team with your fellow teammates, challenge
yourself and enjoy the amazing benefits of being on a mountain expedition. Be open to all the possibilities of what
the journey has to offer and be sure to ask your guides if you have any questions or thoughts. Enjoy!
ROCK CLIMBING INSTRUCTION • MOUNTAINEERING GUIDE SERVICE • INDOOR CLIMBING CENTERS
7125 C COLUMBIA GATEWAY DRIVE • COLUMBIA, MD 21046 • 800-CLIMB-UP • EXPEDITIONS@EARTHTREKSCLIMBING.COM
7
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