Wufoo

Name First Last
Email *
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Your Cell Phone Number ### - ### - ####
Best number to reach you
Birthdate MM / DD / YYYY
What is your first choice for attending camp?
What is your second choice for attending camp?

If you only want to choose one camp, select this camp as your second choice as well.
Emergency contact during camp * First Last
Emergency contact phone number during camp: * ### - ### - ####
Your Occupation
How did you hear about Athletes 4 Cancer (or Kiteboarding 4 Cancer or SUP 4 Cancer)?
The Tenacity Games Magazine Facebook / Twitter John Wayne Cancer Foundation Other survivors who attended a camp Attended a camp Friends Other
Please describe your experience with cancer.

Date of diagnosis, type of cancer, treatment, status.
Do you have any physical restrictions and/or special needs?
What is your swim level?
Surfing/Paddling background (if any)

We expect most to select "None" here, but if you have prior experience, please let us know.
Snowboarding background (if any)

We expect most to select "None" here, but if you have prior experience, please let us know.
What other outdoor sports have you participated in? ie snowboarding, mountain biking, surfing, etc... or none.
Please tell us any issues or topics you would like to discuss at the camp.

These are not brought up under your name -- these are part of a general pool of topics.
Any dietary preferences or requirements?
Have you ever attended a support retreat before? *
Yes No
If yes, please list which one and describe.
Please feel free to provide any additional information that you think would be helpful for us below.
Do Not Fill This Out