Climb Up: New Zealand - December 18-28, 2017

Hope is the Spark that Changes Lives

Climb Up: New Zealand - December 18-28, 2017 (open team)
  1. This application form is to be completed by those who are to participate in Climb Up: New Zealand - December 18-28, 2017 (open team)

    Dates of Climb: December 18-28, 2017
    Cost of event: $6000
    Last day for full payment: 90 days before the trip

    Each climber raises $6,000 with approximately $4,000 going directly to AFCA’s programs. Each climber makes an enormous impact on the lives of children affected and/or infected by AIDS while they travel to a place that is out of this world.

    Your adventure starts on Day 1 and end on Day 11.  Therefore, you will need to secure lodging in Queensland, so your guide can meet you on your start date at 8am at the pre-determined location (see itinerary).  You will also need a place to stay when you finish the trek in Christchurch, so make sure you make reservations before leaving home. Suggestions for where to find accommodation can be found on our tips page.

    If you're interested in other oppportunities for Climb Up: New Zealand, 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.
  11. PASSPORT INFORMATION

    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.
  16. EMERGENCY CONTACT INFORMATION

    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
  21. If you are treated regularly by a doctor, please include their name and contact information:
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  22. REQUESTS

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

  23. Dietary Restrictions(*)
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  24. Other (please specify)
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  25. HEALTH & FITNESS INFORMATION

    All adventurers need to complete the following section with regards to their health. These details are to ensure for a safe adventure.

  26. Date of Birth (mm.dd.yyyy)(*)
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  27. Gender(*)
    Please enter your gender.
  28. Height(*)
    Please enter your height.
  29. Weight(*)
    Please enter your weight.
  30. Blood type(*)
    Please enter your blood type.
  31. What is the general state of your health?(*)
    Please enter your general state of health.
  32. Are you pregnant?(*)
    Are you pregnant?
  33. If so, how many weeks?
  34. Do you have a history of asthma or exercise-induced asthma?(*)
    Do you have asthama?
  35. If so, do you use an inhaler?
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  36. Do you have back or knee problems?(*)
    Do you have back or knee problems?
  37. Please describe
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  38. List any physical limitations or medical conditions that might restrict your ability to fully participate in this adventure(*)
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  39. List any medications you will be taking on the trip, dosages and counter indications:(*)
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  40. List any food, drug, or other allergies:(*)
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  41. Do you have any heart or respiratory problems? Are you a diabetic? Please elaborate.(*)
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  42. Do you have any physical or mental limitations, handicaps or prosthesis?(*)
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  43. Do you have any medical illnesses, disabilities or infirmities that have required the regular care of a doctor?(*)
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  44. OUTDOOR EXPERIENCE...

  45. Describe your mountaineering/outdoor experience:(*)
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  46. Describe your fitness program:(*)
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  47. Have you ever had frostbite or any cold-related injuries?(*)
    Do you have asthama?
  48. Please describe
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  49. TRAVEL INSURANCE INFORMATION

    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.

  50. REGISTRATION FEE

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

    This should be paid our online giving page at givedirect.org, 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.

  51. FURTHER INFORMATION

    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
    - Terms & Conditions and Signed Agreement

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

    American Foundation for Children with AIDS
    6221 Blue Grass Avenue
    Harrisburg, PA 17112
    USA

  52. PAYMENT POLICIES

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

  53. I agree to the payment policies(*)
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  54. SUBMIT YOUR APPLICATION

    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.

  55. Comments (If you have anything further that you'd like us to know)
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  56. 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
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