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Please
provide details of your next of kin, to be contacted
only in the event of accident or illness during the
event: |
| Relationship to you: |
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| First name: |
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| Surname: |
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| Address line 1: |
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| Address line 2: |
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| Address line 3: |
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| Town: |
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| County: |
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| Postcode/Zip code: |
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| Country: |
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| Daytime phone: |
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| Evening phone: |
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| Mobile phone: |
– |
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In the event of an accident of illness while on
the trip, I hereby give permission for Across The Divide
Ltd medical or expedition staff to initiate medical treatment
and to inform my next of kin in case of hospitalisation.
To the best of my knowledge this is a true and
accurate description of my medical history and current condition. I
understand that I am also responsible for informing Across
The Divide of any change in my medical condition, including
pregnancy, which may arise between now and the departure
date. I understand that failure to do so will invalidate
my insurance.
Participants must agree to inform Across The Divide
of any medical or other condition that might affect their
ability to take part in the event.
Please type your name in the box below to indicate you
have read and
agree to the above statement:
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