Register for the Survivor Conference

Thank you for your interest in Survivor Conference! After you submit your application, we will review your eligibility and will get in touch with more info about your fee payment and financial assistance options once your application has been approved.

Any information included in this form is strictly confidential and will only be viewed by Young Adult Cancer Canada (YACC) staff members directly involved in organizing these programs.

This form will time out after about 15 minutes, resulting in a fresh registration page when you hit "submit." You may find it helpful to have information ready on the following topics before you begin: your contact information, emergency contact information, and allergies.

If you have any trouble submitting your form, or if you DO NOT receive a confirmation email after submitting your application, please connect with Lesley at lesley@youngadultcancer.ca and she will provide you with a different format if required.

* Required Field
Volunteer for: *  
Title:
First Name: *    Middle Name:
Last Name: *
E-mail Type:
E-mail: *
Confirm e-mail: *  
Address Type:
Country: *
Address: *
City: *
Province / State: *  
Postal Code / ZIP: *  
Phone: *      Phone Extension:
Gender: *
Date of Birth: *
     

 
Do you have a second phone or cell number?  
(maximum 50 characters)
 
Please tell us your current age. *  
(maximum 50 characters)
 
Are you a patient/survivor or supporter? *  
 
Emergency Contact Information
 
Name of Emergency Contact *  
(maximum 50 characters)
 
Relationship *  
(maximum 50 characters)
 
Emergency Contact Phone (best availability)
 *
  
(maximum 50 characters)
 
Please list any activity restrictions or physical limitations you have that would make it difficult to fully participate in the program. There will be group activities which may include walking, hiking etc.  
(maximum 250 characters)
 
Please list any major stresses, life changes or losses you are currently dealing with in your life (treatments, relationships, finances, other) that you think we should know about.
  
(maximum 250 characters)
 
Nutrition
 
Please indicate any dietary restrictions you have. Check all that apply.  









 
Do you have any other dietary restrictions? What are they?  
(maximum 250 characters)
 
Allergies
 
Are you allergic to any medications? If so, please specify the allergen and indicate treatment required.  
(maximum 250 characters)
 
Are you allergic to any foods? If so, please specify the allergen and indicate any treatment required. For allergies like peanuts and seafood, be specific: can you be in the same room; can they be cooked and served in the same room as you?  
(maximum 250 characters)
 
Are you allergic to latex? If so, please specify treatment required.  
(maximum 250 characters)
 
Do you have any other allergies? If so, please specify the allergen and indicate the treatment required.  
(maximum 250 characters)
 
Please list any allergies you have that are anaphylactic.  
(maximum 50 characters)
 
Do you have an EpiPen? 

Please note: All participants with a known anaphylactic allergy are expected to bring an EpiPen to the event.
  
(maximum 50 characters)
 
What is your preferred t-shirt size?

Please note that while we cannot guarantee your preferred size, we will do our best! *
  




 
Additional Information
 
How did you hear about this event? (i.e. Health Professional, the internet) *  
(maximum 50 characters)
 
Have you attended similar events in the past or other YACC events? If so please tell us the event name and location.  
(maximum 250 characters)
 
Are you concerned that the $199 registration fee might prohibit you from attending this event? *  

 
Are you concerned that the cost of travel to St. John's might prohibit you from attending this event? *  

 
Please note: We don't want money to be the reason you don't attend the Conference. YACC has financial assistance available which is based on your address and need. In addition, YACC is willing to assist you in raising some funds and has a fundraising model that you might find helpful.
 
The Expansion Pack is a fundraising initiative that can not only help you, it can allow you to give back and help more people get to the conference through patient/survivor/supporter-led activities. Do you want to learn more about the Expansion Pack?
 *
  

 
Thank you for taking the time to complete the application. 

We will be in touch very soon.

In the meantime, if you have any questions, please contact Lesley at lesley@youngadultcancer.ca