Registration Form

Thank you for registering with Panacea Adventures. Please fill out the registration form below and submit back to Panacea for processing. Panacea staff will then initiate a phone interview with you, at which time we will send a full application along with any other materials related to your program of interest. If under the age of 18, all signatures must be provided by parent or guardian.

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:

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