Full Name

Email Address

Phone Number

City, Province/State

Gender

Birthday (MM/DD/YYYY)

What expedition or event are you interested in?

Are you currently in active treatment?

Please summarize your cancer journey so far, including your diagnosis and current status

What do you hope to gain from this experience?

Will you need financial assistance to help cover your trip fees or travel costs?
(Note: For expeditions only)

If so, how much money could you raise yourself?

Is there is a close supporter that you'd like to bring with you?
(Please provide their name, email address and relationship to you)

Have you ever attended an adventure trip or retreat with young adult cancer survivors before?

If so, which events have you attended, what year, and with what organizations?

Do you have any allergies or special diets?

Do you have any questions for us?

Instructions

The questions in this form are to help us get to know you a little. Thanks for taking the time to fill it out and we will get back to you within 3-4 days with the next steps to get you signed up!