PDC TEST - Kokoda Trail Treks

Personal Details - Kokoda

Please note that this questionnaire is strictly confidential and is to be completed by ALL Kokoda trekking participants.

Step 1 of 6

Emergency Contact Details
Please provide details for an Emergency Contact at home. We use this information should we need to contact someone on your behalf in the event of an emergency.
Name*
Best Contact Phone Number*

Travel Insurance
Travel Insurance is compulsory for this trek. Your policy must include Emergency Evacuation cover. You are also welcome to arrange your own insurance from any Travel Insurance provider, or arrange Personal Travel Insurance, direct with CoverMore Travel Insurance here.
Which option best describes you?*
- I will use the Travel Insurance as quoted by Back Track Adventures
- I have my own Travel Insurance
- I am undecided at this stage
Name of Travel Insurance Company*
Policy Number*
24 Hour Emergency contact number*

Fitness Questionnaire
This Questionnaire is Strictly Confidential and must be completed by ALL Kokoda Track participants.
The Kokoda Track is a tough, physically and mentally challenging adventure. For all Kokoda Team members, there is a chapter on Kokoda fitness preparation in Back Track's Training and Endurance Guide. Please read this carefully. You are welcome to call us on the Kokoda Assist Line (1300 669 780) if you wish to discuss your training options.
Your present age*
Weight (kg)*
Height (cm)*
Please detail any walking/outdoor/camping trips you have done in the past 3 years with approximate dates and duration.*
What are your current levels of exercise per week? Please indicate type of exercise and time expended.*
Have you read and understood Back Track ‘s Kokoda “Training and Endurance Guide”?*
- Yes
- No
Do you have any questions about fitness training for Kokoda? Would you like a Back Track Kokoda Fitness Advisor to contact you?*
- Yes
- No

Indemnity and Release
In consideration of the acceptance of my Booking Form and deposit to Back Track Adventures, ABN 23910991873, I acknowledge that I have read and understood the Booking Form Terms and Conditions and terms of this Indemnity and Release and:
1. Release and agree to be bound by the terms of same.
2. Except where provided or required by law, or deemed “unfair” in accordance with Australian Consumer Law and as such cannot be excluded, I agree that it is a term of my acceptance of my Booking Form and deposit that for myself, my executors, administrators, heirs, next of kin, successors and assigns, I hereby: (a) waive and release all claims that I may have against Back Track Adventures, its officers, directors, members, volunteers, employees, agents, sponsors, stakeholders, other participants, and any other persons involved in this activity (“the releasees”) including any and all claims for damages caused by negligence or otherwise, arising out of my participation in the activity, together with any costs including legal fees that may be incurred as a result of any such claim whether valid or not and (b) indemnify and hold harmless the releasees and each of them against any such claim that I or my guests or any one or more of my executors, administrators, heirs, next of kin, successors or assigns may have or assert and against any costs including legal fees with respect to such claims.
3. If I am in breach of the terms of my Participation, I agree to recompense the appropriate party/s for all loss and damage (including legal fees) arising out of such breach, including any damage to the party’s reputation.
4. I attest and verify that I am physically and mentally fit, in good health and able to participate in the stated activity and that I have not been advised by a qualified medical practitioner not to participate.
5. I agree to abide by all the rules, regulations and instructions given from time to time, governing this activity and that breach of these rules regulations and instructions will be a breach of the terms of my Participation.
6. I accept that if the activity is cancelled for any reason whatever, refund of any part of my participation fee is governed by the booking “Terms and Conditions.” The event has a privacy policy and the information I have provided on all forms received by me from the releasees is necessary for the conducting of this activity and will only be used for the purpose of conducting this activity.
7. I consent to the publication and/or use in any form of media whatsoever of my name, image, voice, statements or otherwise, without payment or compensation.
8. I have voluntarily entered into this agreement and have read, understood and acknowledged the terms of “Participation” including, exclusion of liability, release, indemnity and information provided in the Booking form.
Declaration
By submitting this Declaration, I hereby acknowledge that I have read and understood (1) The Medical Questionnaire, (2) The Fitness Questionnaire and (3) The Indemnity and Release and declare that the answers to all questions on the Medical and Fitness Questionnaires are true and I have not withheld any information from Back Track Adventures as to the true nature of my fitness and physical well being. I agree to this information being made available to a medical officer or Trek Leader. I agree to provide a Medical certificate from my Doctor certifying his belief in my ability to undertake the Kokoda trek if requested to do so by Back Track Adventures. If after paying a deposit and booking and on examination of these forms and if requested, medical certificate or other information, Back Track Adventures refuse my participation in the trek booked, I will receive back any funds (deposit) paid to Back Track Adventures. Back Track Adventures will not be held liable for any action due to and not limited to costs, inconvenience, and emotional distress resulting from their refusal to accept my booking.

Read the Back Track Adventures Kokoda Booking Terms & Conditions here.
Have you read and understood, and do you accept the Booking Terms and Conditions and terms of this Indemnity and Release*
- Yes
- No
Declaration for Minors
If you are under 18 years at the time of booking, this declaration MUST be signed by your parent or guardian.
By signing this Declaration, I the undersigned certify that I am the parent/guardian of (“the minor”) who will be (_____) years of age on the day of participation of the activity. In consideration of Back Track Adventures accepting the Minor’s application to participate in the activity, I agree to indemnify and shall keep indemnified Back Track Adventures in respect of any losses they or any of them may suffer as a consequence of any claim/s by the Minor and to the same extent as any other participant indemnifies Back Track Adventures pursuant to the Indemnity and Release above.
Parent/Guardian Name*
First Last
Age of "the minor" on the day of trek commencement*
Have you read, understood and agree to this Declaration for Minors.*
- Yes
- No
Phone
This field is for validation purposes and should be left unchanged.

Personal Details - Kokoda

Step 1 of 6

Your Details

Emergency Contact Details

Travel Insurance

Medical Questionnaire

Fitness Questionnaire

Indemnity and Release

Declaration

Declaration for Minors