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Aconcagua Express Trip Application Form

Registering with Aconcagua Express - Step 1 of 3

This is part of the first step in registering for an Aconcagua-Express expedition. This will help us begin to get aquainted with you. To enroll to climb Aconcagua with us, fill out the:

Trip Application along with the
Aconcagua questionnaire and the
Do It Yourself (DIY) Medform.

Along with these 3 forms you must also send a $700 USD deposit *.

Once enrolled you will receive an acceptance package. This package will include the following:

An acceptance letter,
a detailed equipment list,
a medical release form to be filled out by your physician,
a detailed training program,
all of our pertinent contact information, along with all other necessary information regarding your individual expedition.

*See Refunds and Policies section at the bottom of this form.

I have read and I accept the:

1.- Personal Information

Name:

Sex:

Birth Date:

(Month, DD, YYYY)

Place of Birth:

Citizenship:

Passport N°

Passport Issue Date

(Month, DD, YYYY)

Passport Expire Date

(Month, DD, YYYY)

Height:

Weight:

Age:

Occupation:

Address:

Email:

Phones:

Fax:

2.- Expedition Registration Information

Expedition Name:

Dates:

3.- Emergency Contact Information

Name:

Relationship:

Address:

Phones:

Email:

4.- Special Requirements

Special Requirements :

Dietary Restrictions :

5.- Hotel Reservations

Single occupancy

Double occupancy

Other specified :

6.- Payment Procedures
Attached you will find the amount of:
Deposit Reservation US$	Total Balance US$	US$

Form of Payment

Credit Card

		Visa
		Master Card
		Amex

	Credit Card Number:
	Credit Card Name Holder :
	Expire Date:

Check to KL Adventure

Check to KL Adventure and mail to:

Augusto Mira Fernandez 14248, Las Condes, Santiago de Chile, Chile.

Wire transfer to Jackson USA Account:

Wire transfer to Jackson USA Account: Account details, included in the acceptance package.

7.- How did you learn about Aconcagua-Express

Reference from other people

Advertisement (specified):

Internet

Press article (specified):

Other Specified:

* Please note that every payment is under KL Adventure, headquarter of Aconcagua Express.

Cancellation & Refund Policy: If the participant cancels, we cannot refund your deposit or tuition. If we cancel, or you are not accepted due to not passing medical or prior experience screening, there will be a 100% refund. We recommend that you buy cancellation insurance immediately after paying your deposit. This insurance protects you if you are unable to join the expedition for personal or family medical reasons.

Expedition cancellations or changes: Aconcagua-Express reserves the right to cancel an expedition or change the guide team. If Aconcagua-Express cancels, deposit and all paid tuition will be refunded in full. If the participant requests to be transferred to another expedition, the request must be made 90 days before the start date of the expedition.

Aconcagua-Express reserves the right to refuse a person from participation in any program if we find that person to be mentally or physically unprepared. During an expedition, AE reserves the right to require a person to leave, if by the guide’s judgment, that person is unfit to continue. In these cases, there will be no refund of any kind. If the weather or other factors make completing the climbing objective impossible there will be no refund. In the case of the participant's need for a rescue, or the participant leaves the trip before completion, the participant is responsible for any expenses incurred. AE is not responsible for unexpected expenses for which we have no control.

* See also our “what is included and not included” section at the end of each tour description.

I have read, understand, and accept the terms and conditions stated above and acknowledge that this agreement shall be effective and binding upon the parties during the entire period of participation. AE may use my name and picture in all promotional materials.

Participant Signature or Name:

Date:

(Month, DD, YYYY)

Parent or Legal Guardian Signature or Name if under 18 :

Date:

(Month, DD, YYYY)

8.- Security to avoid automatic registrations

*Enter the left numbers

Aconcagua Normal Route	Polacos & Traverse Route	Ameghino & Upper Guanacos Route
Aconcagua South Wall Trek	Tupungato Volcano	Marmolejo
Ojos del Salado Atamaca		Patagonia Trekking

Climb Aconcagua with Aconcagua-Express Expeditions
Augusto Mira Fernandez 14248 Las Condes CP 7591409 Santiago Chile - Phone (56 2) 217 91 01
All Photos in this website are taken by Joaquin Oyarzún, except indicated as *
E-mail: info@aconcagua-express.com

Toll free numbers

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