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Gender:	Male Female
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Passport Information
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	Yes, send me e-mail updates

Challenge deposit (10%):	Everest Base Camp	$500
	Kilimanjaro	$500
	Kalindikhal Glacier Trek	$500
	Baja Kayak	$500
	Surfing in Nicaragua	$500
	Costa Rican Adventure	$500
	Kilimanjaro Gala	$500
Amount:
Frequency:

Payment Options:	Credit Card PayPal

	I have read and agreed with booking terms and conditions
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	I agree to have my contact information circulate among fellow participants

Please NOTE: All Prices are in US Dollars
For any farther question or clarification about payments and payment options, please contact this number: 1-800-444-7789

Medical Information Please select any of the following medical conditions that apply to you
Asthma
Severe attacks of hayfever/allergy
Any form of lung disease
Cancer
Chest surgery
Claustrophobia or Agoraphobia
Behavioral health problems
Epilepsy, seizures, or convulsions
Recurring migrine headaches
Blackouts or fainting
Motion sickness
Recurrent back problems/surgery
Diabetes
Arm or leg problems
High blood pressure
Heart disease/heart attacks
Angina/heart surgery or blood vessel surgery
Hearing loss or problems with balance
Bleeding or other blood disorders
Any type of hernia
Ulcers or ulcer surgery
Bowel disorder
Drug or alcohol abuse
Have been hospitalized in the last year
Awaiting tests/results/surgery
Regularly take prescription medication
Are pregnant
Registered disabled
Suffer from an phobias (heights, flying, water)
Do you have any dietary requirements or allergies?
Do you have any other medical conditions you think we should be aware of?

How did you hear about Adventure Challenges? If you have spoken to a representative please list his or her name here.