intrepid challenges registration form

To join one of our Intrepid Challenges please complete this form online. Your booking will be confirmed on receipt of a non-refundable deposit of AUD$500 if fundraising or AUD$250 for a land only applicant.

Conditions of joining:

Please select one of our charity partners (fundraise or trip cost with $150 donation)
Complete the medical form & fax to +61 3 9597 0797
Read our booking conditions carefully and tick box at end of this form
Fax 'Payment' PDF or call with details (+61 3 9597 0210) to make the deposit

Fields marked with a "*" are required

Challenge Details

Challenge name

Departure date

Charity to support

Preferred payment option

Personal Details - please supply details exactly as they appear in your passport

Title

First name*

Last name*

Street address

Suburb/City

State

Postcode

Country in which you are based

Contact numbers

Email*

Occupation

Passport Details

Date of birth

Nationality

Passport number

Date of issue

Date of expiry

If you need to apply for a new passport – please can you make an application now and send the details as soon as they are received for your booking to be processed.

Next of Kin

Name

Relationship

Street address

Suburb/City

State

Postcode

Country

Contact numbers

Dietary Requirements

Do you have any special dietary requirements?

Yes

If yes, please specify

Bike Size (complete for bike challenges only)

Please indicate your height in centimeters

Accommodation & Room Sharing - accommodation will be provided only on a twin share, single sex basis

Name of friend to share with

Any Additional Information

Where did you see this event advertised?

Additional information

I have read and understood the Booking Conditions

How to pay the deposit to secure your place

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intrepid challenges registration form

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