Youth Program Registration All fall programs are open for registration. If you need any support registering or have questions, 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 Please update any of 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 Child's Name #1* First Last Please select the program(s) you'd like to register for:* Camp Ketcha: Sept. 21, 2019 Fall Hike: Oct. 19, 2019 Brooklyn Boulders: Nov. 16, 2019 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:* Camp Ketcha: Sept. 21, 2019 Fall Hike: Oct. 19, 2019 Brooklyn Boulders: Nov. 16, 2019 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:* Camp Ketcha: Sept. 21, 2019 Fall Hike: Oct. 19, 2019 Brooklyn Boulders: Nov. 16, 2019 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:* Camp Ketcha: Sept. 21, 2019 Fall Hike: Oct. 19, 2019 Brooklyn Boulders: Nov. 16, 2019 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?*
