Print this form and fill it out. Mail or fax to:
Patagonia Mountain Agency
P.O. Box 210516
Auke Bay, AK 99821
Call/Fax 907-789-1960
Web: www.alaska.net/~ptgmtnag/
email: ptgmtnag@alaska.net
PATAGONIA MOUNTAIN AGENCY
EXPEDITION APPLICATION
Expedition:______________________________ Dates:_____________________________
Name: ________________________________________ Age:_____ Ht.:______ Wt.:_______
Address:_______________________________________________________________________
City:_____________________________________
State:_________________________ Zip Code:__________ Country:_________________
In case of emergency contact (name & phone #): ________________________________
Occupation:____________________________________________________________________
Please list any medical conditions you have (include any medications that you
are taking, as well as allergies): ____________________________________________
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Outdoor Experience: List type of trip & duration: _____________________________
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Climbing Experience: __________________________________________________________
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__________________________________________ Highest altitude achieved: _________
Have you done any of the following? ___Traveled on a Glacier, ___Winter Camped,
___Rock Climbed, ___Ice Climbed, ___Belayed, ___Used Ascenders,
___Used Crampons, ___Used Ice Axe.
Do you have a training routine and for how long? Explain? _____________________
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List activities you are involved in on regular basis (hiking, skiing, climbing,
running, etc.):_______________________________________________________________
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