/ THE SHACKLETON CROSSING
30 OCT – 20 NOV 2016
CONFIDENTIAL MEDICAL REPORT & INSURANCE DECLARATION /

Every participant on a Shackleton Legacy Ltd adventure excursuion must complete this form and sign the Declaration of Fitness to Travel. If you have any of the medical conditions listed in Section 1, you and your physician must complete the relevant sections as indicated of this form. If you take anticoagulants (blood thinners), please read and sign the advisory on page 6. Please return your completed forms no later than 90 days prior to departure.

Be assured that the privacy and confidentiality of your medical information will be safeguarded. In the event of on-board medical problems the ship’s physician may require access to your medical file.

I authorize the disclosure of all of the above named patient’s health information by all medical sources to Polar Latitudes, Inc. for the purposes of claims management voluntarily. This authorization shall remain in full force and effect for one year from the date of disembarkation. I have the right to revoke this authorization at any time by writing each source of my medical information. I understand that I may have a copy of this authorization. I understand that I may inspect/copy the information to be used or disclosed. Any disclosure of information carries with it the potential for an unauthorized re-disclosure of said health information by the recipient, resulting in the health information no longer being protected by federal or state confidentiality rules.

APPLICANT INFORMATION

Your Name:

(As it appears
on your passport)

Address

Phone / Email

(Please include international dialing codes if NON UK resident)

Home: / Mobile: / Fax:
Work: / Email:
TELL US A BIT ABOUT YOURSELF
Shackleton’s men dreamt about food. What food do you like? If we can carry it on the expedition, we will do our best to pack it. Please tick as many boxes as you like.
☐ / Hot Food/Sauce / ☐ / Ground Coffee / ☐ / English Tea
☐ / Herbal Tea / ☐ / Vegetarian/Vegan / ☐ / Oatmeal, Nuts & Dried Fruit

At home do you eat breakfast? Do you consider yourself a big eater? Do you snack during the day? Is there anything we should know about your regular diet? Do you have any dietary restrictions?

Briefly describe your outdoor experience including any cold-weather trekking / camping / climbing mountaineering and skiing experience, to assist us in planning the smooth running of your trip :

Describe your weekly fitness routine:

Describe any physical limitations that may be a challenge during The Shackleton Crossing:

Do you practice medicine or do you hold any in-date medical qualifications? (first aid, wilderness EMT, paramedic)

Have you ever sustained frostbite or any cold weather related injury or illness? Please describe:

How would a friend describe your personality? Briefly describe your expectations from the expedition:

All expedition participants will have the unique privilege of:

·  Using the expedition logo for e-mail signatures, outdoor clothing and technical equipment (please contact us for more information).

·  Exclusive access to The Shackleton Crossing ‘Members Only’ webpage.

·  Post-expedition photo sharing using Dropbox.

·  Recommended reading list

RESPONSIBILITIES

Responsibilities of Shackleton Legacy Ltd (that’s us):

1.  Shackleton Legacy Ltd exists to bring history back to life through expeditionary work in South Georgia. We will work closely with each participant to achieve individual and team goals. Shackleton Legacy and its employees, agents, outfitters, and owners act only as the agents for certain tour operators, shipping companies, hotel operators and travel services. Shackleton Legacy Ltd only assumes responsibility for organizing The Shackleton Crossing which includes: the supply of technical polar travel equipment and provisions, the organization of permits, the expedition route plan, the environmental impact assessment, risk assessment, and securing the services of suitably qualified and experienced Mountain Leaders.

Responsibilities of Expedition Participants (that’s you!)

2.  The expedition leader has the right to disqualify anyone at any time during The Shackleton Centenary Voyage if he or she feels the expedition participant is physically incapable and/or if the participant continued involvement will jeopardize The Shackleton Crossing. Neither refunds nor credits are given under such circumstances.

3.  It is the participant’s responsibility to complete a medical and insurance declaration as required for the expedition permit. Shackleton Legacy Ltd will send you these forms upon receipt of a completed application form. It is also the participants responsibility to read the pre-departure information pack including ‘what to expect’ – ‘what to pack – ‘how to prepare/train’. It is the participant’s responsibility to ensure the pre-departure check-list is completed and returned to Shackleton Legacy Ltd prior to departure.

☐ I understand and acknowledge the above responsibilities and agree to observe them.

ITINERARY

4.  Polar travel by nature is very dynamic. Though Shackleton Legacy Ltd will make efforts to minimize any problems, it is important to understand that changes are sometimes necessary and we reserve the right to do this if the expedition is compromised in any way.

☐ I acknowledge the above information about the itinerary.

WEATHER RISK

5.  Shackleton Legacy Ltd (in partnership with Ice Tracks Expeditions & Polar Latitudes) will make every effort to facilitate a successful crossing of South Georgia. Given the nature of weather conditions on the island we cannot be absolutely certain that a crossing will be feasible. In the interest of every participant’s safety, it could be necessary to scale down the expedition plan or modify the overland route within the limitations of the expedition permits.

☐ I acknowledge the above weather risk information

PAYMENT & CANCELLATION

6.  We will not ask you for a deposit until we have submitted the details you provide on this application form to the permitting authorities and have received acceptance of your involvement.

7.  Once your application has been accepted a non-refundable deposit of 20% is required to confirm your position. Reservations are taken on a first come/first serve basis as space is limited to 12 participants plus 3 professional mountain leaders. The final balance may be paid by cheque or bank/wire transfer. The balance is due 120 days prior to departure and we reserve the right to charge the balance or resell the space, if the balance is not received when due. Prices for The Shackleton Crossing are in USD.

Cancellation Policy:

8.  Shackleton Legacy Ltd reserves the right to alter theexpedition planif safety is compromised. If the Crossing is seriously compromised, we reserve the right to cancel the expedition. If cancellation occurs before departure a full refund will be made. If cancellation is necessary following departure,no refunds will be made. Under no circumstances will Shackleton Legacy Ltd be responsible for any expenses incurred by expedition participants.

☐ I acknowledge the above payment & cancellation information.

EXPEDITION LEADERS AUTHORITY

9.  Signing the booking form signifies that, during the overland crossing of South Georgia, you agree to abide by the authority of the expedition leaders who represent Shackleton Legacy Ltd. If, in his/her opinion, your helath or behaviour on the expedition is detrimental to your own safety, comfort or enjoyment of others, you may be excluded from The Shackleton Crossing. If you are excluded from the expedition, or part of it, we will cease to have any responsibility for you and no refund will be made

☐ I acknowledge the above responsibilities and agree to observe these.

APPLICATION CONFIRMATION

10.  Upon receipt of your 20% deposit we will send you comprehensive pre-departure information including what to expect, what to pack, how to prepare, a suggested reading list, and much more. From that point until the departure of the expedition we will be in regular contact with you via phone and e-mail to ensure that all your questions are answered and to help you prepare for this incredible experience. Please contact us at any time with questions.

☐ I acknowledge the above information on application confirmation.

LIABILITY COVER & INSURANCE

11.  Shackleton Legacy Ltd and its employees, agents, outfitters, and owners, assumes no liability for loss of, or damage to, personal property, injury, or loss of life. It is a mandatory requirement for expedition participants to have medical evacuation insurance to undertake The Shackleton Crossing, and proof of this cover will be required for the expedition permit. You should also ensure that there are no explusion clauses limiting protection for the type of activities to be conducted in the sub-Antarctic region. Shackleton Legacy Ltd will supply the specification for this insurance at a later date. Please contact us if you have any questions.

☐ I acknowledge the above responsibilities and agree to observe these.

WAIVER AND RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT

12.  In consideration of being allowed to participate in any way in The Shackleton Crossing Expedition

(30 Oct – 20 Nov 2016) on the island of South Georgia,

I,

13.  the undersigned agree to the terms and conditions for participation. I understand that in joining this Shackleton Legacy Ltd expedition, I will be faced with certain inherent risks to danger in a remote geographic area where shore based hospital treatment is not available.

14.  In making an application to participate in The Shackleton Crossing, I affirm that I know of no medical reason that would prevent me from completing the expedition. I am capable of performing the required exercise to participate, and that I accept the hazards associated with The Shackleton Crossing and will not hold Shackleton Legacy Ltd, Ice Tracks Expeditions or Polar Latitudes, its representatives, or their other participants responsible.

FULL NAME
EMAIL
ADDRESS
CITY
REGION/STATE
POSTAL CODE
COUNTRY
SIGNATURE
DATE
EXPEDITION CHECK LIST
In applying for this expedition I understand that I have certain responsibilities. These include:
(Please tick each item)
☐ / Thoroughly reading and studying pre-expedition information, including the confirmation of personal equipment list. / ☐ / Carefully reading, completing and returning all forms including the confidential medical report, liability waiver, and insurance form. / ☐ / Bringing appropriate clothing and equipment as advised by Shackleton Legacy.
☐ / Purchasing medical evacuation insurance (as specified). / ☐ / Keeping Shackleton Legacy and Ice Tracks Expeditions informed regarding my travel itinerary. / ☐ / Contacting Shackleton Legacy with any questions or concerns relating to the Centenary Voyage or Mountain Crossing

This completes your application.

Thank you! This application can be scanned and returned by e-mail to:

Original signed documentation to be mailed to Shackleton Legacy Ltd, please contact us at the above email for the postal address.

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Shackleton Legacy Ltd (Confidential Medical Report & Insurance Declaration)