Youth Program Registration If you have questions or need any support registering, please call Aaron at 866-442-3529 or email aaron@on-belay.org. Have you registered your child(ren) for an On Belay program before?*YesNoYour Name* First Last Any updates to the following: Phone Number Mailing Address Changes in family member's diagnosis Who in your family is affected by cancer Email*Please provide an email address at which we can send program information and updates Enter Email Confirm Email Phone*Please provide a phone number at which we can call to share program information and updatesMailing Address* Street Address City State / Province / Region ZIP / Postal Code Would you like to request an 'On Belay in a Box' package?Limit one per household. Packages will be mailed the week of February 8th.YesNoWould you like to register for a Winter Program?YesNoChild's Name #1* First Last Please select the program(s) you'd like to register for:*Bear Brook Winter Exploration is open to ages 11-13 & Winter Teen Outdoor Adventure is open to ages 14-18 Bear Brook Winter Exploration: Saturday, Feb 6, 2021, 9:00-3:00 Winter Teen Outdoor Adventure: Saturday, March 6, 2021, 9:00-3:00 Date of Birth* MM DD YYYY Age*On Belay programs are open to youth ages 8-18How are you related to child #1?*ParentGrandparentStep-parentWould like to register another child?YesNoChild's Name #2* First Last Please select the program(s) you'd like to register for:*Bear Brook Winter Exploration is open to ages 11-13 & Winter Teen Outdoor Adventure is open to ages 14-18 Bear Brook Winter Exploration: Saturday, Feb 6, 2021, 9:00-3:00 Winter Teen Outdoor Adventure: Saturday, March 6, 2021, 9:00-3:00 Date of Birth* MM DD YYYY Age*On Belay programs are open to youth ages 8-18How are you related to child #2?*ParentGrandparentStep-parentWould like to register another child?YesNoChild's Name #3* First Last Please select the program(s) you'd like to register for:*Bear Brook Winter Exploration is open to ages 11-13 & Winter Teen Outdoor Adventure is open to ages 14-18 Bear Brook Winter Exploration: Saturday, Feb 6, 2021, 9:00-3:00 Winter Teen Outdoor Adventure: Saturday, March 6, 2021, 9:00-3:00 Date of Birth* MM DD YYYY Age*On Belay programs are open to youth ages 8-18How are you related to child #3?*ParentGrandparentStep-parentWould like to register another child?YesNoChild's Name #4* First Last Please select the program(s) you'd like to register for:*Bear Brook Winter Exploration is open to ages 11-13 & Winter Teen Outdoor Adventure is open to ages 14-18 Bear Brook Winter Exploration: Saturday, Feb 6, 2021, 9:00-3:00 Winter Teen Outdoor Adventure: Saturday, March 6, 2021, 9:00-3:00 Date of Birth* MM DD YYYY Age*On Belay programs are open to youth ages 8-18How are you related to child #4?*ParentGrandparentStep-parentHow has cancer affected your child(ren)*Family member in treatmentFamily member in remissionLost a family memberWho in your family is affected by cancer?*As related to the child(ren) you are registeringMotherFatherSisterBrotherWhat type of cancer is effecting your family?*What hospital or cancer center is providing or was providing treatment?*How did you hear about On Belay programs?*
