APPLICATION

Index this page:

  • Application/Registration
  • MedicalInformation
  • Fitness and Trekking History
  • Leadership Questionnaire
  • Terms and Conditions
  • Participant Agreement, Release and Assumption of Risk

APPLICATION/REGISTRATION 

Serengeti/Mt Kilimanjaro Leadership Development Program

July 4 to July18, 2017

“Thank you for the incredible experience in Africa. We have many new memories we will have for life”. . . John Martincic, PA

Please write clearly:

Full Legal Name: ____________________ Preferred Name:__________________

Mailing Address: ______________________________________________________________

Street/Apt/City/State/Zip

Home Phone: _______________Work:_______________Cell:_______________

Email address: __________________________________

Date of Birth: _______________________ Sex: _________ Height:___________

Weight: _______ Occupation:________________________ T-Shirt Size: _______

In Case of Emergency:

Please notify: __________________________Relationship: _________________

Address: __________________________________ Phone:_________________

Passport number: _____________________ Expiration Date:_________________

Date of Issue: _____________________Place of Issue:______________________

Place of Birth: _____________________ Citizenship: ______________________

Confirmation/Option – Please check the applicable item below:

О          I understand and agree, the base price is for double occupancy

О          I prefer single accommodations at an additional charge as shown in schedule.

General Information:

Have you participated in any similar trips or outdoor courses? ___Yes  ___No

If yes, please list:

On a scale of 1 to 10 (10 is extremely high) how do you rate your fitness level______?

I have read the Terms & Conditions, Release and Medical forms associated with this application & will complete and forward them (mail, fax) within 10 days of this application.

See Dates & Fees then please choose and circle one:

OPTION 1 /OPTION 2 /OPTION 3 (a) /OPTION 3 (b) 

Check/Money Order attached, $______made out to Werner Berger (MMATT)

(Signed)______________________________Date ________________

– – – – – – – – – – – – – – – – – – – – – – –

MEDICAL INFORMATION

Please answer all questions. Provide details where applicable (dates and type of medical treatment etc). Use a separate sheet if necessary.

For the protection of all, Meet Me At The Top, Inc. reserves the right to refuse service at the trekker’s expense due to misrepresentation of any or all information.

1. Have you suffered from frostbite or cold weather injury/illness?   No      Yes.

Please describe:

2. Have you ever experienced any form of altitude illness?        No      Yes.

If yes, where and at what altitude, your rate-of-ascent, medication taken & recovery procedures –

Please describe:

3. Have you had any major accidents, illnesses or operations in the past four years?    No      Yes

Please describe:

4. List any/all physical/mental limitations or medical conditions we should know about or that may restrict your ability to trek (climb and/or descend on steep mountain trails) on this expedition.

5. Do you have back or knee problems?    No      Yes.

Please describe

6. List any/all medications you will be taking on this trip and why:

7. List any/all allergies to food and/or medication:

8. Dietary restrictions (specify):   None   Vegetarian   Other

9. Do you smoke?    No      Yes

11. Are you familiar with standard first-aid and current CPR techniques? No Yes

12. Do you have medical insurance?    No      Yes

If yes, please name insurance provider:

– – – – – – – – – – – – – – – – – – – – – – –

FITNESS/TREKKING HISTORY

This information is very critical, as we strive to cater to your individual needs and goals. The mountains and trails of Africa will not care if you come to them in a high or low state of physical fitness…and the fitter you are the more you will enjoy and appreciate this amazing landscape, environment and experience. It is your responsibility to attain a level of fitness to support you hiking between 5 and 7 hours a day (summit day is longer), with a light pack and at a pace that will not be a detriment to the rest of the team.

If necessary, we will be splitting the group to accommodate pace variances.

Do you workout with any regularity             No      Yes

If no, are you prepared to work diligently on your conditioning prior to the departure date?  No      Yes

Describe what your training regimen will be in preparation for this trek? Will you be using a personal trainer?     No      Yes

Explain/Describe in detail:

If you do workout regularly, what is you fitness routine?

Please describe in detail:

Will you modify your training regimen in preparation for this trek?

If yes, how?

What mountaineering, trekking and/or other outdoor experience have you had (note: non are required)?

Your signature indicates that you understand and comply with the physical fitness requirements for your program

________________________       _________________________

Name of Participant (please print)       Signature of participant:

Date:______________________

– – – – – – – – – – – – – – – – – – – – – – –

LEADERSHIP QUESTIONNAIRE

(Optional)

This is not a right or wrong assessment – simply a benchmark for your growth

1. When assigning tasks my main consideration is systems, my people’s skills or people interests (circle one only).

2. I have had former leadership training: Yes/No. If yes, rate its effectiveness – scale 1(low) to10 (high) ______

3. My reports (or the people I influence) know I expect high performance and high results – scale 1(disagree) to10 (agree) ______

4. On average my reports perform at a level of: scale 1 to 10  ______

5. The main reason for this level of performance is:

6. I am comfortable dealing with conflict – scale 1 (not at all) to 10 (yes) ______

7. I encourage open communication, regardless of the concern/issue – scale 1 to 10 ______

8. I believe that personal feelings and emotions should be kept out of the workplace – scale 1 to 10  ______

9. Spending time on team moral is a waste of time & energy – scale 1 to 10  ______

10. Each member of my team is very aware of the overall objective of our work unit – scale 1 (disagree completely) to 10 (absolutely) ______

11. I spend most of my time coaching reports, planning, dealing with disruptions, being in meetings, on grievances, other ___________________________(circle one only)

12. I expect my reports to live by, and strictly adhere to company policies and procedures – scale 1 (not at all) to 10 (agree whole heartedly) ______

13. I take time to visualize future potential outcomes – scale 1 to 10  ______

14. I ask my people what they need from me so they can be more productive – scale 1 to 10  ______

15. My people mostly solve day to day problems on their own – scale 1 to 10  ______

16. My general outlook on life is positive – scale 1 to 10  ______

17. It takes me a long time to bounce back from criticism – scale 1 to 10  ______

18. I make exceptions to the rules because I do not wish to be classified as an enforcer – scale 1 to 10  ______

19. Individuals perform best when they learn and perform repetitive tasks – scale 1 to 10  ______

20.What does empowering your people mean to you – (single sentence please):

21. My main leadership or performance concerns are:

22. What I am hoping to gain from this Leadership Expedition:

23. Other – comments or questions:

– – – – – – – – – – – – – – – – – – – – – – –

TERMS AND CONDITIONS

Trekking in remote parts of any country carries inherent risk due to weather, potential injury and even death. All of this is beyond our control. Werner Berger – Meet Me At The Top (referred to as WB – MMATT), and its affiliates do their best to reduce any risks and hazards, still there are chances of accidents happening, and for this you and we must agree as follows:

Your bookings are made through WB – MMATT, owned and operated by Werner Berger, 1042 Victory Dr., Yardley, Pa  19067 – 215-642-0083

CANCELLATION AND REFUND POLICY – WB – MMATT strongly urges you to acquire trip cancellation insurance. Due to the heavy cost of government permits and booking fees, WB – MMATT, is forced to adhere to a strict cancellation policy.

If you are unable to travel, and have made all payments, you may replace yourself with an exchange person who has the fitness level required to keep up with the rest of the group for an administrative fee of $25.00.

No refunds can be made if you voluntarily leave a trip for any reason after the trip has begun, including accommodation, transport, sightseeing, meals or services not utilized.

Participant’s whose balances are not received by the due dates risk forfeiture of their place on the trek.

TRIP CANCELLATION INSURANCE: Trip cancellation insurance is highly recommended. You might wish to check with your insurers, and/or on line (example – www.Travelex-Insurance.com – we are not affiliated with them). If you require assistance in obtaining this please let us know.

MEDICAL AND EVACUATION INSURANCE: A condition of joining this trek is that you are insured against medical and personal accident risks. This insurance must include medical coverage, and, at your option, air if you need emergency transportation back to the USA. You should be aware that some policies do not include, or restrict coverage for this type of activity. You must ensure that the policy you do take provides an adequate level of protection and covers you for the activities involved.

PASSPORT: You must carry a valid passport and have obtained the appropriate visas for traveling in Tanzania. Please ensure your passport is valid for 6 months beyond the duration of the trip. It is your responsibility to ensure that you are in possession of the correct visas for the countries you are traveling to. WB – MMATT cannot accept responsibility if you are refused entry to a country or places because you lack the correct visa documentation. The Africa visa may be obtained at the airport in Tanzania.

PARTICIPANT RESPONSIBILITY: You must accept full responsibility for your own well being and that of your offspring; including health and a strong physical conditioning. At your sole discretion you may wish to obtain a physician’s release prior to departure. Your responsibilities include, and are not limited to:

–  Knowing all pre-departure information

– The Tanzanian government requires you to have Yellow Fever vaccination prior to entering the country, or to have a valid exemption certificate. They also recommend malaria and cholera (speak to Werner about all three before acquiring).

–  Physical preparation prior to departure, if you have bravely opted for the climb.

–  Obtaining proper equipment and clothing

–  Conforming to basic standards of personal hygiene while on the trek (to minimize the risk of travel related diseases)

–  Acting with consideration toward all group members and especially with respect African and Swahili customs

–  Adhere to Leave No Trace practices….the environment is fragile; leave it in pristine condition

–  You are expressly prohibited from using illegal drugs while on the trek

–  We highly recommend no use of alcohol while on the trek…and even during your training period.

AIRLINE RESPONSIBILITY:

Standard to all carriers: Air carriers will not be held responsible for any act, omission or event while the passenger is not on-board the designated aircraft or terminal conveyance. Passenger/Airline contracts are in effect while the passenger is on-board each particular aircraft.

CONDITIONS OF THE SAFARI AND CLIMB:

WB – MMATT is committed to making this trek a memorable experience for all, and to help you achieve your personal goals, safely and enjoyably.

WB – MMATT, its owners, sponsors, agents, employees, officers, directors, associates, affiliated companies and subcontractors hereby give notice that they act only as agents for hotels, transportation companies, land operators and suppliers of travel services. WB – MMATT assumes no responsibility or liability in connection with the operation or service of any aircraft, motor vehicle, other conveyance, inn, lodge or hotel which may be used wholly, or in part,

For services to WB – MMATT and its clients. WB – MMATT, its operators, airlines and agents will not be responsible for any act, error, omission, nor for any injury, loss accident, delay, inconvenience, irregularity or damage which may be occasioned by any cause whatsoever. This includes acts of nature, civil disturbance, government restrictions or failure of any means of conveyance to adhere to published schedule.

WB – MMATT reserves the right to change the price of, cancel or withdraw any trek, course or expedition for any reason whatsoever prior to departure. After departure, WB – MMATT reserves the right to alter or omit any part of the itinerary, to substitute hotels or leaders, to change any means of conveyance without notice and without allowance of refund, with liability for increased costs (if any) borne by the trek, course or expedition members. WB – MMATT reserves the right to accept or reject any person as a trek or expedition member at any time.

I understand, and am aware, that during the trek, or expedition in which I am currently participating, or will participate in, under the arrangements of WB – MMATT, certain risks and dangers may arise including, but not limited to: altitude; steep or treacherous terrain; inclement weather; rock fall and other natural occurrences; misuse, failure or loss of equipment; shortage of food or water supply; the hazards of traveling in politically unstable areas; the dangers of civil disturbances and war; the forces of nature; acts or omissions of WB – MMATT; travel by boat, automobile, train, ship, aircraft or other means of conveyance; and accident or illness in remote places without access to medical facilities, transportation, or means of rapid evacuation and assistance.

I certify that I am familiar with the dangers, hazards and risks incident to trekking and expeditions/courses as listed above. And I accept and clearly understand that these hazards and risks may result in personal injuries to myself and others, including paralysis and death, and hereby expressly assume all of the above risks including, the risks of acts or omissions of WB – MMATT, and do hereby expressly agree to hold WB – MMATT harmless and defend them against any and all liability.

In consideration of the services furnished me, and to be furnished me as a member of this trek, and/or expedition, I hereby release WB – MMATT and all the members of the trek, course and/or mountaineering expedition from any and all damages, injuries, losses, or any cause of action which may result in me, my legal representatives or others purporting to exercise statutory or other rights arising out of, or in connection with this expedition. And I hereby assume each and every damage incident to my participation, and agree to indemnify and hold harmless WB – MMATT and all members of the trek, and/or expedition against any sums which they, or any of them may be subject to pay in consequence of any claim or demand by or through me, or resulting from my being a member of this trek, and/or expedition.

– – – – – – – – – – – – – – – – – – – – – – –

PARTICIPANT AGREEMENT, RELEASE, AND ASSUMPTION OF RISK

In consideration of the services of Werner Berger – Meet Me At The Top, their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as “WB – MMATTT”), I hereby agree to release, indemnify, and discharge WB – MMATTT, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

  • I acknowledge that my participation in a guided trekking trip entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity.

The risks include, among other things: the hazards of walking on uneven terrain and slips and falls; being struck by rock-fall, icefall or other objects dislodged or thrown from above; the use of trekking equipment; the forces of nature, including lightning, and weather changes; the risks of falling off the rock, mountain or down an incline; the risks of exposure to insect bites; the risk of altitude and cold including hypothermia, frostbite, acute mountain sickness, cerebral and pulmonary edema; my own physical condition, and the physical exertion associated with this activity.

Furthermore, WB – MMATT employees and their contractors have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant’s fitness or abilities. They might misjudge the weather, or other environmental conditions. They may give incomplete warnings or instructions, and the equipment being used might malfunction.

  • I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.
  • I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless WB – MMATT from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of WB – MMATT’s equipment or facilities, including any such claims which allege negligent acts or omissions by WB – MMATT.
  • Should WB – MMATTT or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.
  • I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have.
  • In the event that I file a lawsuit against WB – MMATT, I agree to do so solely in the Province of Ontario, Canada, and I further agree that the substantive law of that province shall apply in that action without regard to the conflict of law rules of that province. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. While traveling with WB – MMATT I agree to accept the authority of the trip leader or local operator at all times. I am aware that travel within a group may involve compromise to accommodate the diverse desires and physical abilities of group members. I understand that WB – MMATT reserves the right to decline, accept, or retain any person as a member of the group at any time.
  • I acknowledge that WB – MMATT contracts with a network of companies, government agencies and individuals, to assist in the running of this treks. To the best of WB – MMATT knowledge, these third parties are qualified to perform the duties they are contracted to perform. However WB – MMATT will not be held liable for any injury, damage, loss, delay or irregularity that may occur due to the behavior of these third parties.
  • WB – MMATT and its affiliates will not accept responsibility or liability for any traveler who contravenes any law or regulation while in Africa.

By signing this document, I acknowledge that if anyone is hurt, or property is damaged during my participation in this activity, or weather has caused delays, I may be found by a court of law to have waived my right to maintain a lawsuit against WB – MMATT on the basis of any claim from which I have released them herein.

I have had sufficient opportunity to read this entire document. I have read and understand it, and I agree to be bound by its terms.

I agree to all TERMS AND CONDITIONS as stated above.

Date Signed                                                               In the Presence of

__________________                                     __________________

Please print full name                                          Please print full name

_____________________                                    _____________________

Signed                                                                         Signed

Your Contact:  Werner Berger, werner.sri@neptune.on.ca

[1] Please submit a photocopy of your passport (photo page – required for entry to Africa) with your registration documentation….or within a few weeks there after.

To retain formatting please request and email copy (specify for MAC or PC) of these forms (formatting distortion may occur), complete and mail to: Werner Berger -MMATT, 1042 Victory Dr., Yardley  PA  19067

Imagine seeing Wildebeest and Zebra by the 1000’s and the magnificence of Mt. Kilimanjaro sticking up out of the Africa veldt!

Dare to Dream!


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