Register Now For the full list of programs click here To register for another program, please contact Liz Weld at liz@on-belay.org or call 866 44 BELAY. On Belay session date:*Your name:*FirstLastRelation to child:*Child's Name:*Child's Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's age as of program?*On Belay is for youth ages 9-19.Phone:*Email:*Mailing Address:*Street AddressAddress Line 2CityState / Province / RegionZIP / Postal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweCountry*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 treatmentLost a family memberFamily member in remissionOtherIf 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.*Bladder CancerLung CancerBreast CancerMelanomaColon and Rectal CancerNon-Hodgkin LymphomaEndometrial CancerPancreatic CancerKidney (Renal Cell) CancerProstate CancerLeukemiaThyroid CancerOtherIf you chose Other for cancer type above, please explain:How did you hear about On Belay? Please check all that apply.*FriendHospital ReferralEducatorDoctorFamily MemberWebsiteFacebookBrochure*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.
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