Climb Kilimanjaro Registration Form - Project Change
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Climb Kilimanjoro Registration Form

Please fill out the form below to register for the Kilimanjaro climb. Once the form is complete and submitted you will be brought to a page where you can pay the $150 application fee.

Do you have Diabetes?*
NoYes

Do you have a history of Seizures?*
NoYes

Do you have Heart Disease?*
NoYes

Do you have a history of or currently have ashtma?*
NoYes

If you use an inhaler, do you have it with you?
NoYes

Do you have a history of anaphylaxis or allergies?*
NoYes

If so, do you have an EpiPen or other medications with you?
YesNo

Do you have relevant musculoskeletal injuries or related surgeries?*
NoYes

Do you have problems with vision or hearing?*
NoYes

To the best of your knowledge, do you have any other medical or health issues that would prevent you from fully participating in activities regarding this charitable climb?*
NoYes

Do you have international medical insurance?*
NoYes

Are you under the influence of illegal drugs or alcohol?*
NoYes

Do you have any previous climbing experience?*
NoYes

If there is a photo you would like us to use for your campaign page, please upload it now.