Trip Registration Information Trip Registration To book a trip with ProVallone, use this form to send us all of your pertinent information. Name* First Last Cell Phone*Home PhoneEmail* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Age*Gender*MaleFemaleHeightWeightOccupationTrip InfoName of Trip*Trip DatesStart Date End Date Have you skied or climbed with ProVallone before*YesNoHow did you learn about ProValloneEmergency Contact InfoName* First Last Phone*Email* Relation to youFitness and Experience LevelHow would you rate your fitness level*ExcellentAbove AverageAverageBelow AveragePoorExperience LevelIn regard to the specific trip you are participating in, please give a detailed account of your experience and level. Be specific to the individual sports, i.e.: rock and ice climbing, alpine ascents, and skiing.Please describe your average weekly workoutDo you have any questions on the equipment required for this trip*YesNoEquipment QuestionsPlease elaborate on any questions you have regarding equipment.Insurance InfoHave you purchased travel insurance for this trip*YesNoInsurance InfoPlease list your provider and policy numberHave you purchaed rescue insurance for this trip*YesNoRescue Insurance InformationPlease list your provider and policy number.Hotel InformationDo you have accomodations for your trip*YesNoHotel NameReservation DatesStart Date End Date Passport InformationAlways travel with both your passport and a photocopy of your passport.Do you wish to list your passport information*YesNoName as it appears on your passport Passport NumberPlace if IssueDate of Issue Expiration Date Date of Birth Country of CitizenshipMedical InformationClimbing and skiing in general and at high altitude is extremely strenuous. In addition, medical care may not be immediately available in the backcountry. We do not want you to engage in any activity that would be detrimental to your health or which would be opposed by your doctor because of recent illness, injury, surgery, etc. If you have any questions regarding your participation in the trip or expedition, please contact your doctor.Please list any major accidents, illnesses or operations you have had in the past five years:Have you been hospitalized in the past two years? If yes, please explain:Any personal history of Altitude Sickness Ankle or Knee Problems Arm or Shoulder Problems Asthma Back or Neck Problems Bleeding Disorder Blood Disease Cancer Chronic Infections Circulation Problems Currently Pregnant Diabetes Epiliepsy Frostbite Head Injury Hearing Impairment Heart Condition Hernia High or Low Blood Pressure Hypoglycemia Intestinal Problems Intolerance to Cold or Warm Temperatures Irregular Heartbeat or Murmur Joint Dislocations Kidney Problems Migraines Other Respiratory Condition Severe Sprains Seizure Disorders Vision Impairment Please elaborateIf you marked any of the above, please explain below. Include dates, severity, treatment, current symptoms and limitations:MedicationsList any/all medications that you take regularly or intermittently and why:Medical RestrictionsList any/all physical limitations or medical conditions that may restrict your ability to participate in this program.AllergiesList any/all allergies to food and/or medication:Please Verify* I verify that the information I have provided on ProVallone Participant Medical History is true, complete and correct: I have read and agree to the Deposit and Cancellation Policy I have downloaded the Provallone Waiver. I will sign this and send back to Provallone. PhoneThis field is for validation purposes and should be left unchanged.