MasterPeace Walk Nepal 2019 – Application form

Program: Wednesday November 6th (14:00h/2:00 PM) - Friday November 15th (7:00h/7:00 AM) 2019

!! Please return this form by e-mail to peacewalk@masterpeace.org and add a digital portrait photo and a copy of your passport!!

Formal name (as specified in passport, including all first names)

Given name

Home address

Zipcode, city

Mobile Phone (business and/or private)

E-mail address (required)

Date of birth

Place of birth

Nationality

Passport number (must be valid up till 6 months after your return from Nepal)

Date of issue passport

Place of issue passport

Upload a copy of your passport

Upload a passport photo

Business / Job / Education details

Contact details in home country in case of emergency (Name, relation, telephonenr)

Travel insurance company

Travel insurance number

Diet and allergies Information (if any)

Length in centimeters

Do you have any medical/healthcare licenses?
(For the Dutch EHBO/BHV etc.)

Medical Information
HAVE YOU SUFFERED AN ILLNESS OR PHYSICAL INJURY RECENTLY?
Please provide us with any detailed information about your medical
needs. It is possible to put a list of your medication in a sealed envelope
and hand it to the program management. Only to be used in case of
emergency. This information will be held strictly confidential.

Please inform us about anything which is important in relation to the programme and activities (incl. physical condition).

Can you bring your own small 2persons trekking tent?
NoYes

Do you agree with the terms as mentioned below
NoYes

By filling in this form and sending it by email I agree:
1. to pay 20% of the agreed fee of € 1850,= within 4 weeks of your application and the resuming amount at the latest on 1st September 2019.
2. that in case I need to cancel the trip after 1st October 2019, I will forfeit 100% of the agreed and paid fee.
3. that in case the Masterpeace Walk is cancelled, e.g. due to less than the required number of participants or to other reasons, the amount paid is refunded.
4. Account details: Stichting MasterPeace: NL25TRIO 0390 3713 35. Additional reference: Donation MasterPeace Walk 2019 NEPAL.
5. Dutch Income Taxes clarification:
- Although Stichting Masterpeace is an ANBI, the fee amount is NOT deductible as a donation within the normal specifications of the Tax laws.
- For those who would like to deduct the fee as educational costs, invoices will be send on request and are specified without VAT.

I understand that:
6. The MasterPeace Walk is not organized by a professional travel agency but by a group of volunteers in cooperation with MASTERPEACE.
7. The MasterPeace Walk and everything that comes with it, is at my own risk and responsibility. I also fully appreciate the fact that there may be risks, hazards and dangers involved in such a wildlife walk to which I would be subject.
8. I wait with my travel arrangements until the Program Management has given a final GO on the Masterpeace Walk 2019. This will be ultimately around the beginning of July 2019. Any arrangements made before the final GO date are for your own account and financial risk.
9. MasterPeace complies to the AVG Privacy Policy Guidelines.

I furthermore state that:
10. I will take care of necessary medical protection and obligated visa.
11. My general health is good and there is nothing, which renders me, unfit to undertake this walking event.
12. Together with my heirs, executors and administrators I hereby release from any liability: MASTERPEACE EU office, MASTERPEACE Nepal, and the Program Management: Santosh Bidari, Punam Khadgi, Marcella Bos, Heidi Los and anyone involved in organizing the Peace Walk through Nepal. And from all or any claims that could accrue to me or my heirs, executors and administrators arising out of my participation in the said MasterPeace Walk or in any related activities. I further indemnify and hold them harmless against any claims whatsoever may arise.