Childhood Cancer and The Family - Together in 2000
Child & Teen Registration Form
(Each Child requires a completed Form - Please photocopy or submit for each additional child/teen)
 Pre-registration required by June 30, 2000
 This Child/Teen will be participating in the following program days:
      Friday        Saturday      Sunday

First Name:                                                                   Last Name:
    
Address:                                                                        
 
City:                                                                                  Province/Country:
     
Postal Code:                                                                 Phone Number:
     

Birth Date
MM/DD/YY		 Age:
As of Aug.18 2000		 Sex: Male
Female		 Is your child comfortable in an English speaking environment?
Yes             No
If no what language?:

Saturday Day Trip Choice: Zoo Sports Fan Package Sites & Sounds Tour
Saturday Night Child/Teen BBQ &Movie ($10.00) Yes             No
 
T-Shirts Size: Child's: Medium X Large Adult's: Medium Large

Health and Medical Information

   Health Card #:                                         Province:                                               Non-Canadian (Insurance Carrier)
         

Please indicate which category appropriately describes this child:
  child is currently receiving treatment for cancer    child had cancer but is currently off treatment
   child is a sibling of a child with cancer or a
         history of cancer		    child is bereaved sibling since (MM/DD/YY)
        
other (please explain)
Does your child require increased or one to one supervision:   Yes                        No
                                                                                                                          Explain:
 
Please indicate if your child has any dietary restrictions or specials dietary needs:

Please indicate if your child has any of the following allergies:
Allergy Yes No Reaction
 Hayfever/Environmental      
 Bee Stings      
 Peanuts      
 Medication      
 Other (food/latex etc.)      

Please indicate if your child will require medication while participating in the children's program of the conference
Yes No Possibly

If yes, please list.
Medication Dose Each Time Time of Admin. Reason Special Instructions

Does your child require Wheelchair Access?:       Yes              No

For adult registration click here
Note: Child/Teen registration form is to be enclosed with the completed adult registration form.

Si vous voulez ces formulaires en francais, appelez notre bureau au 1-800-363-1062