Evacuation Assistance

Please complete the following form with your personal and travel information in order to purchase the Aconcagua assistance service.

The information provided will be used exclusively for the issuance of your coverage and must match with your personal travel documentation.

TRAVEL INFORMATION
Destination

Plan

Date of the start of your expedition

Enter the date you will enter Aconcagua Park.
Assistance will be valid for the duration of your expedition.

BENEFICIARY INFORMATION
Name

Last Name

Date of Birth

Age

Gender

Nacionality

Country of Residence

Passport number / ID

Phone number

Enter your personal phone number, where we will contact you directly if you require assistance.

EMERGENCY CONTACT INFORMATION
Name and Last Name

Phone

DECLARATION OF FITNESS AND EXCLUSION CLAUSE REGARDING PRE-EXISTING MEDICAL CONDITIONS

 The undersigned hereby declares, under oath, that they do not suffer from, have not suffered from, nor are they currently undergoing medical evaluation, treatment, monitoring or follow-up for any illness, injury, condition or medical history that may, directly or indirectly:
•be aggravated by high-altitude mountaineering activities;
•compromise their physical, mental or sensory capacity;
•increase the risk of accident, serious illness or death;
•hinder, delay, prevent or place at risk an evacuation or rescue operation.
______________
Statement Regarding Medical Conditions
In particular, and without this list being exhaustive, the undersigned declares that they do not currently have, nor have they previously had, any of the following conditions:
1. Cardiovascular conditions, whether diagnosed or not, including but not limited to: congenital or acquired heart disease, arrhythmias, history of myocardial infarction, uncontrolled arterial hypertension, heart failure, syncope, pacemakers or coronary stents.
2. Respiratory or pulmonary conditions, including moderate or severe asthma, chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, history of high-altitude pulmonary edema (HAPE), pulmonary embolism, reduced ventilatory capacity, or dependence on inhaled medication.
3. Neurological or sensory conditions, such as epilepsy, loss of consciousness, recurrent vertigo, severe visual or hearing impairment, balance disorders, cerebrovascular accidents (stroke), or neurological sequelae.
4. Musculoskeletal injuries or conditions, including surgeries, prostheses or reconstructions (particularly involving the ankle, knee, hip, spine or shoulder), recent fractures, functional limitations, chronic pain or joint instability.
5. Psychiatric or psychological conditions, whether diagnosed or not, including major depressive disorder, severe anxiety disorders, personality disorders, post-traumatic stress disorder (PTSD), suicidal ideation, or any condition that may affect judgment, behavior or decision-making in extreme environments.
6. Current or recent use of substances or medications that may alter consciousness, coordination or physical response, including alcohol, recreational drugs, psychotropic medications, sedatives, opioids or any medication contraindicated for high-altitude activities.
7. Any other medical condition, whether congenital or acquired, known or unknown to the undersigned, that may represent a risk in environments involving high altitude, extreme cold, hypoxia, isolation or prolonged physical exertion.
______________
LEGAL EFFECTS OF THIS DECLARATION
The undersigned expressly acknowledges and agrees that:
•Any omission, false statement or inaccuracy in the medical information provided shall constitute a breach of this declaration, and may result in the loss of access to evacuation and rescue services related to the undisclosed or misrepresented condition.
•The service provider may deny, suspend or cancel evacuation or rescue services if a medical condition incompatible with the activity is identified.
•Any costs and expenses arising from an event directly related to an undisclosed or excluded medical condition shall be the sole responsibility of the undersigned.
•The undersigned expressly waives and releases any claim, action, demand or compensation against the service provider, organizing company, guides, physicians, rescuers or any related third parties.

I declare that I have read, understood, and fully accept the Declaration of Fitness and Exclusion Clause Regarding Pre-Existing Medical Conditions.