Re: May 2010 trek –“Standing Ovation Werner!” –Penny K., AZ, USA
Mt. Everest Base Camp Trek – (date to be announced)
(Please copy and mail back to Meet Me At The Top, 1042 Victory Dr., Yardley, Pa 19067 or email werner@MeetMeAtTheTop.com…you may need to adjust for document distortion or email Werner for a ‘clean’ copy)
Please write clearly:
Full Legal Name: ___________________Preferred Name:_______________
Mailing Address: ____________________________________________________________________________
Home Phone: _________________Work:________________Cell:____________________
Email address: __________________________________
Date of Birth: _______________________ Sex: _______ Height:__________ Weight: _______ Occupation:_____________________
T-Shirt Size: ________
In Case of Emergency:
Please notify: _____________________Relationship: _________________
Address: __________________________ Phone:____________________
Passport number: __________________ Expiration Date:_____________
Date of Issue: _____________________Place of Issue:___________________
Place of Birth: _____________________ Citizenship: ___________________
Confirmation/Option – Please check the applicable item below:
О I am selecting Option A1, A2, B1, B2 or C (please circle one)
О I understand and agree, the base price is for double occupancy
О I prefer single accommodations (definitively available in Kathmandu and in most of the trail lodges) at an additional cost of $350
Have you participated in any similar trips or outdoor courses? ___Yes ___No
If yes, please list:
On a scale of 1 to 10 (10 is extremely high) how do you rate your fitness level___?
I have read the Terms & Conditions, Release and Medical forms of this application and will forward them on or before the deposit due dates.
(When copying and printing these pages, please adjust for distortion or request an email copy. This font and layout looks crazy on the printed page)
___ . ___ . ___ . ___ . ___ . ___
Please answer all questions. Provide details where applicable (dates and type of medical treatment etc). Use a separate sheet if necessary.
For the protection of all, Meet Me At The Top, Inc. reserves the right to refuse service at the trekker’s expense due to misrepresentation of any or all information.
1. Have you suffered from frostbite or cold weather injury/illness? □No □Yes.
2. Have you ever experienced any form of altitude illness? □No □Yes.
If yes, where and at what altitude, your rate-of-ascent, medication taken & recovery procedures –
3. Have you had any major accidents, illnesses or operations in the past four years? □No □Yes
4. List any/all physical/mental limitations or medical conditions we should know about or that may restrict your ability to trek (climb and/or descend on steep mountain trails) on this expedition.
5. Do you have back or knee problems? □No □Yes.
6. List any/all medications you will be taking on this trip and why:
7. List any/all allergies to food and/or medication:
8. Dietary restrictions (specify): □None □Vegetarian □Other
9. Do you smoke? □No □Yes
11. Are you familiar with standard first-aid and current CPR techniques? □No □Yes
12. Do you have medical insurance? □No □Yes
If yes, please name insurance provider:
___ . ___ . ___ . ___ . ___ . ___
This information is very critical, as we strive to cater to your individual needs and goals. The mountains and trails of Nepal will not care if you come to them in a high or low state of physical fitness…and the fitter you are the more you will enjoy and appreciate this amazing landscape, environment and experience. It is your responsibility to attain a level of fitness to support you trekking between 4 and 7 hours a day, with a light pack and at a pace that will not be a detriment to the rest of the team.
If necessary, we will be splitting the group to accommodate pace variances.
Do you workout with any regularity □No □Yes
If no, are you prepared to work diligently on your conditioning prior to the departure date? □No □Yes
Describe what your training regimen will be in preparation for this trek? Will you be using a personal trainer? □No □Yes
Explain/Describe in detail:
If you do workout regularly, what is you fitness routine?
Please describe in detail:
Will you modify your training regimen in preparation for this trek?
If yes, how?
What mountaineering, trekking and/or other outdoor experience have you had (note: non are required)?
Your signature indicates that you understand and comply with the physical fitness requirements for your program
Name of Participant (please print) Signature of participant:
___ . ___ . ___ . ___ . ___ . ___
TERMS AND CONDITIONS
“Trekking in remote parts of this Himalayan country carries inherent risk due to weather, potential injury and even death. All of this is beyond our control. Meet Me At The Top, Inc. and its affiliates do their best to reduce any risks and hazards, still there are chances of accidents happening, and for this you and we must agree as follows:
Your bookings are made through Meet Me At The Top, Inc. a Nevada company, owned and operated by Werner Berger, 1042 Victory Dr., Yardley, Pa 19067 – 215-642-0083
CANCELLATION AND REFUND POLICY – Meet Me At The Top, Inc. strongly urges you to acquire trip cancellation insurance. Due to the heavy costs of government permits and booking fees, Meet Me At The Top, Inc. is forced to adhere to a strict cancellation and refund policy.
The Application deposit and registration fee of $750.00 is non-refundable (under any circumstances).
All balances are due prior to July 15, 2013.
Full refunds, less the registration fee, will be provided up to May 30, 2013. If you are unable to travel, and have made all payments, you may replace yourself with an exchange person who has the fitness level required to keep up with the rest of the group for an administrative fee of $25.00.
No refunds will be made if you voluntarily leave a trip for any reason after the trip has begun. Also, no refunds will be made for any accommodation, transport, sightseeing, meals or services not utilized.
Participant’s whose balances are not received by the due dates risk forfeiture of their place on the trek.
All refund requests must have been received in writing prior to May 30, 2013.
TRIP CANCELLATION INSURANCE: Trip cancellation insurance is highly recommended. You might wish to check with your insurers, and/or on line (example – http://www.Travelex-Insurance.com). If you require assistance in obtaining this please let us know.
MEDICAL AND EVACUATION INSURANCE: A condition of joining this trek is that you are insured against medical and personal accident risks. This insurance must include medical coverage, air ambulance and helicopter rescue services. You should be aware that some policies do not include, or restrict coverage for this type of activity. You must ensure that the policy you do take provides an adequate level of protection and covers you for the activities involved. You must carry proof of insurance (e.g. your insurance certificate) with you on the trek; if you cannot provide this at the start you will not be allowed to continue with your trip and will not be entitled to any refund for services not provided. If you are not able to get your evacuation insurance please contact us. Do not attempt to get this Insurance in Kathmandu.
PASSPORT: You must carry a valid passport and have obtained the appropriate visas when traveling in Nepal. Please ensure your passport is valid for 6 months beyond the duration of the trip. It is your responsibility to ensure that you are in possession of the correct visas for the countries you are traveling to. Meet Me At The Top, Inc cannot accept responsibility if you are refused entry to a country or places because you lack the correct visa documentation. The Nepalese visa may be obtained at the airport in Kathmandu, yet, it is recommended you obtain it prior to departure
PARTICIPANT RESPONSIBILITY: You must accept full responsibility for their own well being; including health and a strong physical condition. At your sole discretion you may wish to obtain a physician’s release prior to departure. Your responsibilities include, and are not limited to:
– Knowing all pre-departure information
– Physical preparation prior to departure
– Obtaining proper equipment and clothing
– Conforming to basic standards of personal hygiene while on the trek (to minimize the risk of travel
– Acting with consideration toward all group members and especially with respect Nepali and Sherpa customs
– Adhere to Leave No Trace practices….the environment is fragile; leave it in pristine condition
– You are expressly prohibited from using illegal drugs while on the trek
– We highly recommend no use of alcohol while on the trek…and even during your training period.
Standard to all carriers: Air carriers will not be held responsible for any act, omission or event while the passenger is not on-board the designated aircraft or terminal conveyance. Passenger/Airline contracts are in effect while the passenger is on-board each particular aircraft.
CONDITIONS OF THE TREK:
Meet Me At The Top, Inc. is committed to making this trek a memorable experience for all, and to help you achieve your personal goals, safely and enjoyably.
Meet Me At The Top, Inc., its owners, sponsors, agents, employees, officers, directors, associates, affiliated companies and subcontractors (herein after collectively referred to as “MMATT”), hereby give notice that they act only as agents for hotels, transportation companies, land operators and suppliers of travel services. MMATT assumes no responsibility or liability in connection with the operation or service of any aircraft, motor vehicle, other conveyance, inn, lodge or hotel which may be used wholly, or in part,
For services to MMATT and its clients. MMATT, its operators, airlines and agents will not be responsible for any act, error, omission, nor for any injury, loss accident, delay, inconvenience, irregularity or damage which may be occasioned by any cause whatsoever. This includes acts of nature, civil disturbance, government restrictions or failure of any means of conveyance to adhere to published schedule.
MMATT reserves the right to change the price of, cancel or withdraw any trek, course or expedition for any reason whatsoever prior to departure. After departure, MMATT reserves the right to alter or omit any part of the itinerary, to substitute hotels or leaders, to change any means of conveyance without notice and without allowance of refund, with liability for increased costs (if any) borne by the trek, course or expedition members. MMATT reserves the right to accept or reject any person as a trek or expedition member at any time.
I understand, and am aware, that during the trek, or expedition in which I am currently participating, or will participate in, under the arrangements of MMATT, certain risks and dangers may arise including, but not limited to: altitude; steep or treacherous terrain; inclement weather; rock fall and other natural occurrences; misuse, failure or loss of equipment; shortage of food or water supply; the hazards of traveling in politically unstable areas; the dangers of civil disturbances and war; the forces of nature; acts or omissions of MMATT; travel by boat, automobile, train, ship, aircraft or other means of conveyance; and accident or illness in remote places without access to medical facilities, transportation, or means of rapid evacuation and assistance.
I certify that I am familiar with the dangers, hazards and risks incident to trekking and expeditions/courses as listed above. And I accept and clearly understand that these hazards and risks may result in personal injuries to myself and others, including paralysis and death, and hereby expressly assume all of the above risks including, the risks of acts or omissions of MMATT, and do hereby expressly agree to hold MMATT harmless and defend them against any and all liability.
In consideration of the services furnished me, and to be furnished me as a member of this trek, and/or expedition, I hereby release MMATT and all the members of the trek, course and/or mountaineering expedition from any and all damages, injuries, losses, or any cause of action which may result in me, my legal representatives or others purporting to exercise statutory or other rights arising out of, or in
connection with this expedition. And I hereby assume each and every damage incident to my participation, and agree to indemnify and hold harmless MMATT and all members of the trek, and/or expedition against any sums which they, or any of them may be subject to pay in consequence of any claim or demand by or through me, or resulting from my being a member of this trek, and/or expedition.
PARTICIPANT AGREEMENT, RELEASE, AND ASSUMPTION OF RISK
In consideration of the services of Meet Me At The Top, Inc., their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as “MMATT”), I hereby agree to release, indemnify, and discharge MMATT, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:
- I acknowledge that my participation in a guided trekking trip entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity.
The risks include, among other things: the hazards of walking on uneven terrain and slips and falls; being struck by rock-fall, icefall or other objects dislodged or thrown from above; the use of trekking equipment; the forces of nature, including lightning, and weather changes; the risks of falling off the rock, mountain or down an incline; the risks of exposure to insect bites; the risk of altitude and cold including hypothermia, frostbite, acute mountain sickness, cerebral and pulmonary edema; my own physical condition, and the physical exertion associated with this activity.
Furthermore, MMATT employees and their contractors have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant’s fitness or abilities. They might misjudge the weather, or other environmental conditions. They may give incomplete warnings or instructions, and the equipment being used might malfunction.
- I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.
- I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless MMATT from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of MMATT’s equipment or facilities, including any such claims which allege negligent acts or omissions by MMATT.
- Should MMATT or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.
- I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have.
- In the event that I file a lawsuit against MMATT, I agree to do so solely in the Province of Ontario, Canada, and I further agree that the substantive law of that province shall apply in that action without regard to the conflict of law rules of that province. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. While traveling with MMATT I agree to accept the authority of the trip leader or local operator at all times. I am aware that travel within a group may involve compromise to accommodate the diverse desires and physical abilities of group members. I understand that MMATT reserves the right to decline, accept, or retain any person as a member of the group at any time.
- I acknowledge that MMATT contracts with a network of companies, government agencies and individuals, to assist in the running of this treks. To the best of MMATT knowledge, these third parties are qualified to perform the duties they are contracted to perform. However MMATT will not be held liable for any injury, damage, loss, delay or irregularity that may occur due to the behavior of these third parties.
- MMATT, its affiliates, vendors and/or business partners will not accept responsibility or liability for any traveler who contravenes any law or regulation while in Nepal.
By signing this document, I acknowledge that if anyone is hurt, or property is damaged during my participation in this activity, or weather has caused delays, I may be found by a court of law to have waived my right to maintain a lawsuit against MMATT on the basis of any claim from which I have released them herein.
I have had sufficient opportunity to read this entire document. I have read and understand it, and I agree to be bound by its terms.
I agree to all TERMS AND CONDITIONS as stated above.
Date Signed In the Presence of
Please print full name Please print full name
Your Contact: Werner Berger, werner@MeetMeAtTheTop.com
 Please submit a photocopy of your passport (photo page – required for entry to Nepal) with your registration documentation….or within a few weeks there after.
Copy and print these forms (please adjust for format distortion which may occur while copying and printing) and mail to:
Meet Me At The Top, Inc.. 1042 Victory Dr., Yardley, Pa 19067. For more information contact Werner at Werner@MeetMeAtTheTop.com
Come with us to create life changing memories – see the Testimonials: “The trek was the best experience ever; life changing!!!!” –Lisa Whittall-Miller, ON