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:

Please contact Suzanne Dunbar – Patient/Parent Advocate at sdunbar@cw.bc.ca if you have any other questions or concerns about the trip.

I would like to acknowledge that we could not do this trip without the amazing support from donors from Balding for Dollars and Power to Be. Also, our amazing Medical staff who volunteer their time to attend the trip to support our Patients. Please note we can only take 10 Teens on this trip. We take in to consideration any new applicants but it is base on a first to respond list. If we have more than 10 teens apply we will have a wait list and you will get first in line for next years trip. It is important and appreciated to get all forms/waivers back to me by the deadline set in furture correspondence.

Take Care,

Teen Adventure Application

Teen Adventure Application Form

Suzanne Dunbar

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Teen Adventure Application

Teen Adventure Application Form

Suzanne Dunbar

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