Climb Kili - Open team Sept 23 - Oct 4, 2017

Hope is the Spark that Changes Lives

Climb Kilimanjaro - Open Team (Sept 23 - Oct 4, 2017)
  1. This application form is to be completed by those who are to participate in Climb Mount Kilimanjaro: Team De La Rosa – Conquering Kilimanjaro

    Dates of Climb: September 23 - October 4, 2017
    Cost of event: $8000
    Last day for full payment: 90 days before the trip

    If you're interested in other oppportunities for climbing Mount Kilimanjaro, look here.

    After you have completed the application form below you will also need to submit a $500 non-refundable and non-transferable deposit via our online donation page, in order to be part of the team. More details are given below.

  2. Full Name(*)
    Please type your full name.
  3. Preferred Name(*)
    Please type your preferred name.
  4. Address(*)
    Please type your address.
  5. City(*)
    Please type your city.
  6. State / Province(*)
    Please enter your state/province.
  7. Zip / Postal Code(*)
    Please enter your zip/postal code..
  8. Country(*)
    Please type your country.
  9. Email(*)
    Please type your email address.
  10. Phone(*)
    Please enter your phone number.

    Please complete your passport information below. If you do not currently have a valid passport, please send through the information to us as soon as it becomes available.

  12. Citizenship(*)
    Please type your citizenship.
  13. Passport Number
    Please enter your passport number
  14. Expiry Date (mm.dd.yyyy)
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  15. Place of issue
    Please enter your passport's place of issue.

    In the case of an emergency whilst participating in our event, please complete the following information.

  17. Name(*)
    Please enter the name of the person to be contacted in case of an emergency.
  18. Relationship(*)
    Please let us know what is your relationship with the emergency contact.
  19. Phone(*)
    Please include the telephone number of your emergency contact person.
  20. Email(*)
    Please enter the email address of your emergency contact person

    This section is with regards to accommodation and dietary requirements of event participants.

  22. Room Type(*)

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  23. Would you like to share a double room or tent? With whom?
  24. Dietary Restrictions(*)
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  25. Other (please specify)
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    All adventurers need to complete the following section with regards to their health. These details are to ensure for a safe adventure.

  27. Date of Birth (mm.dd.yyyy)(*)
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  28. Gender(*)
    Please enter your gender.
  29. Height(*)
    Please enter your height.
  30. Weight(*)
    Please enter your weight.
  31. What is the general state of your health?(*)
    Please enter your general state of health.
  32. Do you have a history of asthma or exercise-induced asthma?(*)
    Do you have asthama?
  33. How often do you use an inhaler?
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  34. Do you have back or knee problems?(*)
    Do you have back or knee problems?
  35. Please describe
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  36. List any physical limitations or medical conditions that might restrict your ability to fully participate in this adventure(*)
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  37. List any medications you will be taking on the trip(*)
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  38. List any food, drug, or other allergies:(*)
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    Here are some extra questions which refer specifically to climbing of Mount Kilimanjaro. This further helps us in providing for a safe trip.

  40. Describe your mountaineering/outdoor experience(*)
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  41. Describe your fitness program(*)
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  42. Have you ever had frostbite or any cold-related injuries?(*)
    Have you ever had frostbite or any cold-related injuries?
  43. Please describe
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    NOTE: You are responsible for procuring your own travel medical insurance, including emergency evacuation insurance. AFCA must receive a copy of your travel insurance prior to your departure.

    Please be sure to read your travel insurance benefits and coverage information to ensure that you have medical coverage for the country you are visiting.


    A $500 non-refundable registration fee needs to be paid along with this application.

    This should be paid our online giving page at, which can be found here. In the Comments field under 'Section 2 Donation Information', type in the host country location and dates for the team you are joining.


    After completion of this application form, you will also need to download the following forms which need to be read and signed and then sent to AFCA. If the participant is a minor, the forms must be signed by a parent/guardian of minor.

    - Voluntary Release form
    - Signed Agreement

    These completed forms should be either scanned and emailed to Tanya Weaver at or mailed to AFCA at the address below.

    American Foundation for Children with AIDS
    1520 Greening Lane
    Harrisburg, PA 17110


    On advancement of registration fee to AFCA and by checking the check box below, you agree to AFCA's payment policies.

  48. I agree to the payment policies(*)
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    You've now completed the application form. Please make sure the information is correct and then complete the code in the box below and click on submit.

  50. Comments (If you have anything further that you'd like us to know)
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  51. Please enter the code without spaces between the letters in the box below(*)
    Please enter the code without spaces between the letters in the box below
      RefreshInvalid Input

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American Foundation for Children with AIDS
1520 Greening Lane
Harrisburg, PA 17110

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