Register for Retreat Yourself BC 2019
Thank you for connecting! Please use the form below to register for Retreat Yourself BC between November 28-December 2, 2019.

A
ny 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. 

You may find it helpful to have information ready on the following topics before you begin: your contact information, emergency contact information, doctor and hospital contact information, medications, allergies, and a 200-300 word bio about yourself we will combine with the other bios so you can get to know the other participants a little better before the event.

If you have any trouble submitting your form, please connect with Karine at karine@youngadultcancer.ca and she will provide you with a different form if required.

 

* Required Field
First Name: *    Middle Name:
Last Name: *
E-mail: *
Confirm e-mail: *  
Country: *
Address: *
City: *
Province / State: *  
Postal Code / ZIP: *  
Phone: *     

 
Personal Information
 
Please provide a cell or other contact number we may use to reach in you case of emergency. *  
(maximum 50 characters)
 
What is your date of birth? *  
(maximum 50 characters)
 
Please tell us your current age. *  
(maximum 50 characters)
 
Gender:  
(maximum 50 characters)
 
Name of emergency contact *  
(maximum 50 characters)
 
Relationship *  
(maximum 50 characters)
 
Emergency Contact Home Phone  
(maximum 50 characters)
 
Emergency Contact Work Phone  
(maximum 50 characters)
 
Emergency Contact Other Phone  
(maximum 50 characters)
 
Are you a survivor or supporter? *  
 
Medical Information - Your Physical Health

To help us better prepare for the weekend an to ensure you have an amazing time, please complete the following information.

 
Are you being treated for any other health concerns we should be aware of? (i.e. seizures, diabetes, asthma, hypertension, panic attacks, pregnancy, etc.?)
  
(maximum 250 characters)
 
Is there any information or special instructions we should be aware of?  
(maximum 250 characters)
 
How are you feeling physically at the present time?

If not applicable, please indicate N/A. *
  
(maximum 250 characters)
 
Are you in pain at the present time? (On a scale of 1-10, where 10 is a high level of pain) *  










 
Medical Information - Your Mental Health

The following questions are related to your mental state at the present time. We ask these questions to help us understand the issues you are dealing with when coming to Retreat Yourself, both issues related to your cancer experience as well as other challenges you are facing.

 
Please list any major stresses or life changes you think we should be aware of so we can provide you with the right support while at the event.

If not applicable, please indicate N/A.
  
(maximum 250 characters)
 
How is your morale? (On a scale of 1-10, where 10 is very good) *  










 
Are you able to climb stairs?
  



 
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, volleyball etc.

If not applicable, please indicate N/A. *
  
(maximum 250 characters)
 
Nutrition
 
Please indicate any dietary restrictions you have (check all that apply)  








 
Allergies
 
Are you allergic to any medications? If yes, please specify the allergen and indicate treatment required.  
(maximum 250 characters)
 
Are you allergic to any foods? 

If yes, please specify the allergen and indicate 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 the allergen and indicate the treatment.  
(maximum 250 characters)
 
Are you allergic to insect bites? If yes, please specify the allergen and indicate the treatment required.  
(maximum 250 characters)
 
Do you have any other allergies? If yes, please specify the allergen and indicate the treatment required.  
(maximum 250 characters)
 
Please list any allergies you have that are ANAPHYLACTIC.  
(maximum 250 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: we cannot guarantee t-shirt sizes, we will do our best! T-shirts will be unisex sizes.
 *
  




 
Additional Information
 
How did you hear about this event? For example, health professional, internet search etc. *  
(maximum 50 characters)
 
Have you attended a similar event in the past, or other YACC events? If yes, please tell us the event name and location.   
(maximum 250 characters)
 
Will the cost of travel prohibit you from attending the event?

Please note: If you are unable to attend because of financial restraints, please discuss this with us. YACC has travel assistance available, which is based on address of residence, need, as well as on a first-come-first-serve basis. 

In addition, YACC is willing to assist you in raising the travel funds and has a fundraising model that you may find helpful. *
  

 
We want to know about you!

YACC is gathering information for each and every participant that will be compiled and distributed to all participants at the start of the event, to help us get to know each other and help us stay connected after the weekend.

Please let us know a little about you in 200-300 words. 

Here are some general questions you may use to get the ball rolling:
1) What is the biggest challenge of being a cancer survivor/supporter?
2) How has cancer changed your life?
3) What do you hope to gain from this event?
4) Where are you professionally (school/work), personally (single, married, family)?
5) What are you future personal or professional goals?
6) What do you like to do in your spare time?
7) Do you have any training or special interest in therapies? For example: yoga, meditation, art therapy, Reiki, Qigong etc. 

You may want to type your bio elsewhere and paste it into the box. *
  
(maximum 1999 characters)
 
Don't forget to submit your application at the bottom of the page!

Thanks for taking the time to complete this application form. We will be in touch with you very soon.

If you have any questions, please contact Karine at karine@youngadultcancer.ca!

 
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