Participation Registration Form

Please enter your information in the form below. Please submit one form

for each climber.

Name

First Name

Last Name

Which Route

How did you find out about Urth Expedition?

Do you have previous climbing experience?

Do You have medical Insurance

Do you have any medical conditions?

Are you allergic to anything?( bee stings?)

Selec Do you have a history of orthopedic problems?

Do you have a history of cardiac problems?

Fear of heights?

Group Leader:

Full Name as it Appears on Passport

Passport Country

Passport Number

Passport Issue Date

Passport Expiration (MM/DD/YYYY)

Emergency Contact Name*

Emergency Contact Phone*

Emergency Contact E-mail*

Dietary Restrictions*

T-shirt size

Acknowledgement

Also, I am fully aware that climbing Kilimanjaro and going on Safari might involve some risks. Although the company will provide me with first aid equipment and a knowledgeable guide, I understand that injury, sickness, and death can occur on Mountain and Safari. Urth Expedition will bear no responsibility for those events. Signature

Date of Birth ( MM/DD/YYYY )

Phone Number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Additional Information

Terms & Conditions

I agree to Urth Expeditions Terms & Conditions as stated in the booking form.

See Urth Expedition Terms & Conditions

In consideration of the services of Urth Expedition, 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 “Urth Expedition"), I hereby agree to release, indemnify, and discharge Urth Expedition, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

1. I acknowledge that my participation in mountain climbing activities 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; slips and falls; rope burns; pinches, scrapes, twists and jolts that could result in scratches, bruises, sprains, lacerations, fractures, concussions, or even more severe life threatening hazards; being struck by rock fall or other objects dislodged or thrown from above; the use of equipment; the forces of nature, including lightning and rapid weather changes; the risk of falling off the rock; exposure to temperature and weather extremes which could cause hypothermia, hyperthermia (heat related illnesses), heat exhaustion, sunburn, dehydration; and exposure to potentially dangerous wild animals, insect bites, and hazardous plant life; the negligence of other participants or persons who may be present; my own physical condition, and the physical exertion associated with this activity.

Furthermore, Urth Expedition employees 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 illnesses in particular Acute Mountain Sickness in all its manifestations from altitude related mild to severe including Ataxia, HAPE and HACE; environmental conditions. They may give incomplete warnings or instructions, and the equipment being used might malfunction.

2. 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.

3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Urth Expedition 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 Urth Expedition equipment or facilities, including any such claims which allege negligent acts or omissions of Urth Expedition.

4. Should Urth Expedition 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.

5. 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.

6. In the event that I file a lawsuit against Urth Expedition, I agree to do so solely in the United Republic of Tanzania. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining document shall remain in full force and effect.

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against Urth Expedition 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 understood it, and I agree to be bound by its terms.

Participation Registration Form

info@UrthSafari.com

1.512.787.4628