Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Gender
*
Country of Residence
*
Nationality
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Occupation
Company Name
How did your hear about us?
Languages Known
*
Emergency Contact Name
*
Emergency Contact Relationship to you
*
Emergency Contact Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Mobile
*
Emergency Contact Phone
Emergency Contact Email
*
What is your motivation for joining us on The Courage Journey? (Please elaborate)
*
What do you hope to gain from The Courage Journey? (Please elaborate)
*
Blood Group
*
Height (cm)
*
Weight (kg)
*
Medical Conditions
*
Do you presently have or have had any of the medical conditions listed below? Please tick all that apply.
Please note that this programme is not advised for pregnant women and those suffering from chronic health problems such as epilepsy, heart ailment, psychological problems and physical disabilities.
If you ticked any of the above, please provide more information here.
Are you currently taking any medication for treatment of a medical condition? If yes, please list name, dose, and duration of the medicine. If no, just write 'Not applicable'.
*
Do you smoke, consume alcohol / tobacco products / addictive drugs or narcotics in a regular basis? If yes, please provide additional information below. If no, just write 'Not applicable'.
*
What, if any, trekking experience do you have?
*
What exercise do you do regularly? What is your level of fitness?
*
Declaration
*
Declaration of the Participant:
I hereby willingly undertake to attend The Courage Journey for my well-being at my own risk and will not lay blame under any circumstances for any loss, damage or possible injuries to person or property. I further indemnify Continuum Partners Ltd against all claims and suits and state that my legal heirs shall also not lay any claim against Continuum Partners Ltd in this regard. Furthermore I state that I have recently undertaken or will undertake a medical examination as part of the registration for this programme, and take full responsibility for my physical condition. I confirm that Continuum Partners Ltd will bear no liability should any medical matter arise during this programme and that I shall be financially responsible for any consequential medical expenses. I confirm that all information provided is true and accurate and agree to it being shared with Continuum Partners Ltd. I acknowledge and fully understand the Continuum Partners Ltd terms and conditions.
Thank you for you interest in The Courage Journey and submitting your registration form for the programme. We look forward to having you with us!
Aside from the online registration form, we also kindly ask that you fill in the Terms & Conditions and Medical Form , provide us with a colour copy of your passport and passport-sized photographs, and follow the payment instructions - all as per the guidance laid out in the registration email that you have received. Please note that we operate on a first come, first serve basis, so in order to avoid disappointment please fill out all parts of the registration process as soon as possible to reserve your place.
Please also remember that all participants are responsible for securing their own medical, emergency rescue, and travel insurance.
We will review your application and get back to you as soon as possible. We may also contact you directly in case we require any further information before confirming your place on the programme.
If you have any questions or trouble along the way, please don't hesitate to contact us!
Namaste,
