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contact info

Surname (according to passport):

Name (according to passport):

Street name:

House number:

Postal code:

Municipality:

Telephone:

Email:

Date of birth:

reis selectie info

Chosen expedition:

Departure date:

Are you travelling with other people? If yes, who?:

Relevant travelling experience:

Height:

Weight:

Shoe size:

Personal data and experiences

Mandatory to complete, this will remain confidential. This data is processed to ensure the security of each expedition.

Physical fitness

Level

Type of profession

What is your profession?:

medical data

Medical comments:

fear of heights

knee issues

back/hip issues

issues with breathing

allergies (please specify below)

blisters quickly

Food allergies:

Other, specific medical comments:

Insurance details

(if no insurance through Into the Arctic (in partnership with Allianz) - mandatory to report

I have an assistance policy through:

Policy number:

Insurer's phone number:

Blood type:

I would like insurance through Into the Arctic (in cooperation with Allianz):

Reisbijstand (3,3€/dag binnen Europa, 7,7€/dag voor Groenland). Minimumpremie 25€.

Travel assistance excluding luggage insurance (€2.4/day within Europe, €4.8/day Greenland). Minimum premium 25€

Cancellation insurance (6.5% of the travel sum)

Annulatie + bijstand “Exclusive selection” (7,95% van de reissom – niet voor Groenland)

I wish to receive more information about insurance

We can only offer insurance for participants with residence in Belgium.

More info on all insurance options can be found on our insurance page .

Contactpersoon in geval van nood

Contact person:

Mobile phone contact person:

Questions or remarks?

Questions and/or remarks: