Nepal Trek - Registration form

(may be combined with Tropical Thailand Tour and Healing Retreat) .

Name:____________________________________

Date of Birth: ___________

Phone(s): __________________________________

Address: _________________________________________________

Email: _________________

Any special interests in Nepal, hobbies,  etc.: _____________________________________________________

Any medical conditions affecting you or others on the trip (cardiovascular, lung, diabetes, hemophilia, allergies, seizures, psychological, etc.):
______________________________________________________________

______________________________________________________________

Any medications you are taking: ____________________________________

_____________________________________________________________

Can you walk 30 minutes at an easy pace without discomfort or excessive fatigue?

YES___ NO___ MAYBE__

Emergency Contact Name: __________________________________ 

Phone: __________________________

Do you want University of Natural Medicine Credits (two, in Nutritional Medicine) for this trip ($150)? ___

RELEASE FROM LIABILITY: Center for Community Development and Research (CCODER), FDH Foundation, The University of Natural Medicine (UNM), and Dr. Adiel Tel-Oren, from any liability in the event of injury, illness, death, or any other misfortune resulting from this trip to Nepal.

Signed: __________________________________________

Date: _________________

Please send this form with your check, payable to ENF (Empower Nepal Foundation) to:

Dr. T, Ecopolitan Building, 2409 Lyndale Ave South, Minneapolis, MN   55405  

STATEMENT OF INFORMED CONSENT: Since this trek is demanding, occasionally strenuous (up and down hills, 3-6 hours hiking per day on average), occurring in remote areas of Nepal, and involving unique cultural and environmental concerns, I hereby agree to read thoroughly, understand, and follow responsibly all the information and instruction given to me by Dr. Tel-Oren, FDH Foundation and CCODER, including the observation of ecologica / environmental / social / cultural practices, the necessary physical preparation for the trek (broken-in hiking shoes supporting the ankles, climbing up and down stairs or hilly terrain, having sufficient aerobic capacity for trekking), and the avoidance of behaviors risky to my health while under the stress of airplane transportation and exposure to physical challenges. I understand that this is necessary to prevent mishaps affecting all the other participants, and that such mishaps would be my responsibility alone.

Signed: _________________________________________

Date: _____________________