Wufoo

Name * First Last
I am.... *
Male Female
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? *
Emergency contact during camp * First Last
Emergency contact phone number during camp: * ### - ### - ####
Your Occupation *
How did you hear about this program? *

Please be as descriptive as possible.
Please describe your experience with cancer. *

Date of diagnosis, type of cancer, treatment, status.
How do you feel you would benefit from attending a Camp Koru? Basically, why do you want to go? *
Do you have any physical restrictions and/or special needs? *

If yes, please describe.
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?

We shop and cook very healthy, mostly organic ingredients for our camp.
Have you ever attended a camp (for cancer survivors) before, either as a camper or a counselor? *
Yes No
If yes, please list which one(s) and explain.
Please feel free to provide any additional information that you think would be helpful for us below.
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