Thank you for your interest in Panacea Adventures!

Please fill out the Panacea Adventure Registration application below. Once a registration form is submitted online, Panacea Adventures will contact you for a brief follow up conversation to discuss details of the adventure and the full application process.

A limited amount of scholarships are available. We are committed to providing need-based financial aid so that participants from all economic backgrounds can participate. If you are interested in requesting financial aid for an adventure, please contact us for information on financial aid to determine whether or not you are eligible to apply. Aid is awarded based on need and is determined by the Federal Poverty Guidelines, so you will need to provide information about family income, the number of people that this supports, and any unusual financial circumstances you are facing. If no aid is needed, you only have to fill out the adventure registration form.

Registration Form

Participant Name : Participant Email Address:  Legal Guardian Name: Legal Guardian Email Address: Primary Phone: Mailing Address: Participant Age: Participant Gender: What Strengths Will You Contribute to the Program What Do You Hope To Get Out Of Panacea Adventures Check the following activities which you have tried before: Camping
Surfing
Sea Kayaking
White Water Rafting
Rock Climbing
Backpacking
 High Ropes Course
None
Please Describe Your Experience:Name three Short Term Goals (1-6 months):Name Three Long Term Goals (3-5 years):Name Three Life Goals:Check Relevant Medical History For Participant: Asthma
Allergies
Diabetes
Muscular or Skeletal Conditions
High Blood Pressure
High Cholesterol
Recent Surgeries
Other
None
Please Describe Severity and Details of Relevant Medical History:Check Relevant Mental Health History For Participant: Depression
Anxiety
Suicidal Thoughts
Suicide Attempts
Hospitalization
Other
None
Please Describe Severity and Details of Relevant Mental Health History:Please List Current Medications Used:Other Comments: