Teen Adventures Application | Balding For Dollars

SECTION 1: TO BE COMPLETED BY THE PARENT / LEGAL GUARDIAN

These events are open to all teens with a history of cancer or blood disorders that are between the ages of 13 and 18 before the date of the trip. Please read the information accompanying this form before completing the application. We also recommend that medical concerns be discussed with your family physician prior to completing the application.

Please indicate here which Adventure you are applying for. Indicate your first and second choice in case your first choice is not available. See the enclosed Teen Adventure Announcement Sheet for more information about each adventure.

Which Adventure you are applying for?*

Trip #1 Rafting/Whistler Adventure - May 22 – 25th 2019
Trip #2 Surfing/Whale watching in Tofino – July 2 – 6th 2019

TEEN’S NAME*

First Last

GENDER*

Male
Female
Other

BIRTHDATE*

AGE*

(As of December 31, 2018)

HEIGHT*

WEIGHT*

T-SHIRT SIZE*

SMALL
MEDIUM
LARGE

SHOE SIZE*

ADDRESS*

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

HOME PHONE*

WORK PHONE*

CELL PHONE*

PARENT EMAIL*

TEEN EMAIL*

DEPENDENT NO.

FAMILY DOCTOR*

DOCTOR PHONE*

ATTENDING ONCOLOGIST*

DIETARY RESTRICTIONS*

Does the teen have any special dietary restrictions?

ALLERGIES:

Does the teen have any known allergies (i.e. food, plants, insects, drugs, etc.)? Provide details:

SECTION 2: TO BE COMPLETED BY THE TEEN

The information contained in this section will be used to help select the teens that will be coming to a Teen Adventure. Please answer the questions as completely and as honestly as possible.

How many previous camps for teens with a history of cancer or blood disorder have you attended?*

What years?*

If you have or have never attended camp previously, please explain why you think you should be chosen to go on an Adventure*

DIAGNOSIS*

DIAGNOSIS DATE*

SUBSEQUENT DIAGNOSES*

SUBSEQUENT DIAGNOSIS DATE*

Is there anything specific you would need assistance with on the trip (e.g. help with dressings, taking medications, walking in difficult conditions)? Please explain:*

Briefly describe your experience with cancer or blood disorder.*

How do you feel your life has been changed from your experience with cancer or blood disorder; what do you feel you have gained and lost?*

What do you feel that you can gain from a Teen Adventure in terms of your illness? What do you have to offer your fellow teens on an Adventure?*

Briefly describe your paddling/kayaking ability.*

Briefly describe your swimming ability.*

(Regular kayaking/paddling equipment, life jackets and helmets (if necessary) will be provided and must be worn at all times.)

Please tell us a little about yourself, your family, your hobbies, your likes and dislikes.*

Do you have any physical, mental or social challenges for which consideration should be given?*

Are there any special family, social or other circumstances that you would like to be taken into account? What concerns do you have about attending a Teen Adventure?*

Parent Questionnaire

In order for us to ensure that each trip remains a safe and successful experience for all concerned, please answer the following questions.

Does your teen require any special supervision? i.e. one to one or small group?*

Are there any safety concerns that you have in regards to your teen’s participation in any of these adventures?*

Has your teen been away from home before? If so, for how long?*

If your teen has a cell phone please give us the number for our files.*

Are there any other issues you would like to discuss? Please contact us by phone (604-875- 2345 X6477) or e-mail (sdunbar@cw.bc.ca) if you have any questions or concerns.

SIGNATURE*

Programs

Teen Adventures Application – Register Here

SECTION 1: TO BE COMPLETED BY THE PARENT / LEGAL GUARDIAN

SECTION 2: TO BE COMPLETED BY THE TEEN

Parent Questionnaire