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On Belay session date:*

Your name:*

FirstLast

Relation to child:*

Child's Name:*

Child's age as of program?*

Phone:*

Email:*

Mailing Address:*

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

*Please include the name and phone number of someone we may call, in the event of an emergency and we are unable to reach you.

Emergency Contact Name*

Emergency Contact Phone*

Has your child attended an On Belay program before?*

If your child has a sibling attending, would they prefer to be separate or together during the program?

How has cancer affected your child?*

Family member in treatment
Lost a family member
Family member in remission
Other

If you chose Other above, please explain:

On Belay is doing research on the type of cancer effecting the families we serve. Please select the box that most accurately reflects the type of cancer effecting your family.*

If you chose Other for cancer type above, please explain:

How did you hear about On Belay? Please check all that apply.*

*Please note: On Belay is a recreational program designed to provide all participants with a sense of security, comfort and most of all fun. If for any reason your child is not able to respect other participants, facilitators and the goals of the program; On Belay staff will call you and ask you come pick up your child.