Teen Adventures Application

Teen Adventure Application Form

Name of Parent or Guardian
First Name Last Name
Name of (2nd) Parent or Guardian (if applicable)
First Name Last Name
Email (parent or guardian)

Email (2nd parent or guardian) if applicable

Phone Number (parent or guardian) home
Phone Number (parent or guardian) Cell
Phone Number (2nd parent or guardian) Cell
Phone Number (parent or guardian) Work
Phone Number (2nd parent or guardian) Work (if applicable)
Name of Participant
First Name Last Name
Email (participant)

Cell phone (participant)
Address
Street Address Street Address Line 2 City State / Province / Region ZIP / Postal Code Country

Teens Date of Birth (must be 13-18 yrs old to attend)
To which gender identity does your teen most identify with
Height/Weight
T-shirt size
Shoe size
Diagnosis
Diagnosis date
Subsequent Date of diagnosis (if any)
Briefly describe your Teen's experience with their diagnosis
Allergies
Dietary Retrictions
Family Doctor (name and phone number)
Oncologist/Hematologist
Tell us about your teen...hobbies, family, dislikes and likes
What do you feel your teen will gain most coming to a Teen Adventure
Has your Teen attended any other camps or been away from home for an extended period of time
Would your teen need any special assistance (medically, physically, emotionally)
Are there any safety concerns your have with your teen or would they require any special supervision during the trip
Is there anything else you would like to share with the Medical/Power to Be team attending the trip that would help make this a positive experience for your Teen:

Teen Adventures Application – Register Here

General Information

Application Date(Required)

Recipient Name(Required)

First Last

Primary Email(Required)

Secondary Email

(alternate contact)

Phone Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Select which term you are applying for(Required)

How did you hear about this bursary?

Eligibility Criteria

Select which option applies to you:

How many times have you received a Balding for Dollars bursary award?

Have you volunteered for Balding for Dollars in the past year?

BCCH Doctor

Last year of treatment

Education Information

What school will you attend?

What is your program of study?

How long is your program?

Estimated tuition?

Required

Letter of Acceptance from educational institution

Accepted file types: pdf, Max. file size: 50 MB.

PDF Document Must Be Uploaded

Consent 1(Required)

I hereby certify that the above information is true and correct, and I understand that any false statement(s) may disqualify me from receiving this bursary.

Consent 2(Required)

I understand that it is my responsibility to complete the Bursary Payment Request form by the deadline date for payment of the bursary to be processed. Further, I understand that late forms will not be accepted and will result in my bursary award being forfeited.

Consent 3(Required)

I hereby give Balding for Dollars permission to use my name and image on promotional materials, including print, online and social media, in association with any testimonials I have given to promote Balding for Dollars programs.

Please tell us about your and your family’s experience with Balding for Dollars. Which program(s) did you find most beneficial? What else could we do to support you?

Date

Number

Teen Adventures Application

Teen Adventure Application Form

General Information

Eligibility Criteria

Education Information

Required

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Teen Adventures Application

Teen Adventure Application Form

General Information

Eligibility Criteria

Education Information

Required

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