Event Registration Form Expedition
- Select - Jungle Expedition, Taman Negara, Malaysia May 13-22, 2025 Overland Expedition, Ladakh, India August 28 - 7 September, 2025 Sailing Expedition, Malacca Straights November 12-23, 2025
Country of Passport Issuance
Select Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belau Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Saint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo (Kinshasa) Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Republic of the Congo (Brazzaville) Reunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (Dutch part) Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia/Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (UK) United States (US) United States (US) Minor Outlying Islands United States (US) Virgin Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Country of Residence
Select Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belau Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Saint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo (Kinshasa) Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Republic of the Congo (Brazzaville) Reunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (Dutch part) Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia/Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (UK) United States (US) United States (US) Minor Outlying Islands United States (US) Virgin Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Level of Prior First Aid/Medical Training
- Select - None CPR/AED Certified Basic First Aid WFA/AFA WAFA/AAFA WFR/AFR WEMT/AM WALS/AMD Assistant Medical Officer (AMO) EMT-B EMT-I AEMT Paramedic Advanced Care / Critical Care Paramedic Physicians Assistant (PA) Nurse - Enrolled/Assistant Registered Nurse (RN) Nurse Practitioner (NP) Medical Doctor (MD) Other
Prior Wilderness/Austere/Expedition Experience & Expertise (If none put N/A)
Health & Wellbeing Information
Do you have any known allergies?
Please describe your allergies and the treatment you generally receive if exposed to your allergen.
Do you have any special dietary requirements?
Please describe your dietary requirements
Are you currently or do you expect to be taking any regular medications at the time of expedition?
Please list the medications you take/anticipate taking and the condition for which they are taken
Do you have any known physical limitations, disabilities, medical or mental health conditions that may affect your ability to take part in the expedition? This question is not asked to be exclusionary, rather to allow us to provide the best support possible to ensure that you get the most from the expedition.
Please list the relevant conditions and any support you may need with them. We will reach out to you directly to discuss. Please note that logistics and costs in meeting any special requirements may vary and are not included in the base fee.
Is there any other personal information you wish to disclose that may aid the organizers in providing the most inclusive, high quality experience possible?
What do you wish to disclose?
Emergency Contact Information
Preferred Payment Method
- Select - Wise (Preferred) Credit Card Telegraphic Transfer / Bank Deposit E-Wallet / QR Code (For Malaysian Participants Only)
Billing Address
Country
Select Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belau Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Saint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo (Kinshasa) Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Republic of the Congo (Brazzaville) Reunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (Dutch part) Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia/Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (UK) United States (US) United States (US) Minor Outlying Islands United States (US) Virgin Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Liability Waiver
I understand that participation in one of AEMED's courses and programs (the "activities") involves inherent risks and dangers, including but not limited to hazards associated with medical procedures, office environments and their surrounds. I understand that such activities are often physically and emotionally demanding. I further understand that I will be participating in emergency medical training scenarios with other students under circumstances where accidents, mistakes or other circumstances may result in injury to me. To enable AEMED to provide its courses and programs and to allow EXPED and X3SI to instruct the same and as partial consideration for my participation in such courses and programs: 1. I voluntarily choose to participate in the activities and accept and assume the risk of bodily injury, death or property damage occurring while participating in them notwithstanding such risks and dangers. 2. I, for myself and my heirs, successors, assigns and personal representatives, hereby absolve, release and discharge AEMED, EXPED and X3SI, their respective agents, employees, officers, directors, volunteers and successors and assigns (hereinafter referred to individually or collectively as "Releasees") from any blame or liability or causes of action whatever, whether based on tort, contact, express or implied, or any other theory, arising from, or on account of, property damage, economic loss, personal injury or death, related to or arising from my participation in the activities, including, without limitation, any liability or causes of action based on, asserting, or caused by, the negligence of Releasees or of other persons. 3. I further hereby covenant not to sue and agree to indemnify and hold harmless Releasees from any liability or causes of action whatsoever arising from property damage, economic loss, personal injury or death, related to my participation in the activities, including, without limitation, any liability or causes of action based on, asserting, or caused by, the negligence of Releasees or of other persons and including, without limitation, liability for loss of consortium which may be asserted by my spouse or others, and agree to pay the legal fees and expenses of Releasees associated with the defense of any claims brought in violation of this Agreement. Provided, however, that nothing herein shall operate to preclude me from making a claim for workers compensation if I would be entitled to make such a claim in the absence of this Agreement. 4. This Agreement shall be governed by the laws of Wyoming, USA. By signing this Agreement I further agree that this will be the exclusive jurisdiction in which I may bring any suit related to or arising out of the activities. This Agreement shall be binding on me and on my heirs, successors, assigns and personal representatives. If any provision herein is invalid or unenforceable, in whole or in part, that shall not affect the validity or enforceability of any other provision.I understand that completing this form and entering my full legal name below shall to all intents and purposes have the same legal effect as a handwritten signature.
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