Youth Program Registration If you have questions or need any support registering, please call 866-442-3529 or email info@on-belay.org. Have you registered your child(ren) for an On Belay program before?* Yes No Your 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 HiddenUnable to come to an in-person program? Would you like to request an 'On Belay in a Box: Spring & Summer Edition'' package?Limit one per household. Yes No HiddenWould you like to register for Spring & Summer Programs? Yes No Child's Name #1* First Last Have you filled out a On Belay Waiver for this Child?* Yes No Please fill out this form: https://forms.gle/GBDjd4Hayo1kwyLv9 This form only needs to be filled out ONCE [per child] in the 2022 calendar year. Please select the program(s) you'd like to register for:* Rippleffect Ocean Kayaking: September 17th, 2022 (Ages 8-18) Mt. Agamenticus: October 15th, 2022 (Ages 8-10) NH Climbing and Fitness: November 5th, 2022 (Ages 8-18) Date of Birth* Month Day Year Age*On Belay programs are open to youth ages 8-18 How are you related to child #1?* Parent Grandparent Step-parent Would like to register another child? Yes No Child's Name #2* First Last Please select the program(s) you'd like to register for:* Rippleffect Ocean Kayaking: September 17th, 2022 (Ages 8-18) Mt. Agamenticus: October 15th, 2022 (Ages 8-10) NH Climbing and Fitness: November 5th, 2022 (Ages 8-18) Date of Birth* Month Day Year Age*On Belay programs are open to youth ages 8-18 How are you related to child #2?* Parent Grandparent Step-parent Would like to register another child? Yes No Child's Name #3* First Last Please select the program(s) you'd like to register for:* Rippleffect Ocean Kayaking: September 17th, 2022 (Ages 8-18) Mt. Agamenticus: October 15th, 2022 (Ages 8-10) NH Climbing and Fitness: November 5th, 2022 (Ages 8-18) Date of Birth* Month Day Year Age*On Belay programs are open to youth ages 8-18 How are you related to child #3?* Parent Grandparent Step-parent Would like to register another child? Yes No Child's Name #4* First Last Please select the program(s) you'd like to register for:* Rippleffect Ocean Kayaking: September 17th, 2022 (Ages 8-18) Mt. Agamenticus: October 15th, 2022 (Ages 8-10) NH Climbing and Fitness: November 5th, 2022 (Ages 8-18) Date of Birth* Month Day Year Age*On Belay programs are open to youth ages 8-18 How are you related to child #4?* Parent Grandparent Step-parent How has cancer affected your child(ren)* Family member in treatment Family member in remission Lost a family member Who in your family is affected by cancer?*As related to the child(ren) you are registering Mother Father Sister Brother What 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?* Δ
