Teens
Teens!
Questions?
Why Adventure
2024 Trip report
Parents
Parents
Healing
Hard things
Courage
Teens
Teens!
Questions?
Why Adventure
2024 Trip report
Parents
Parents
Healing
Hard things
Courage
GUARDIAN INTAKE FORM
PLEASE COMPLETE THE FORM BELOW
Participant Legal Name
*
First Name
Last Name
Participant Preferred Name
Participant Preferred Pronouns
Participant Phone
*
(###)
###
####
Participant Email
*
What is the best time to reach the participant for a brief interview?
Treating Hospital
*
Who is the main point of contact at the treating hospital?
Participant Address
This is the address we'll send their check for participating in our research
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent/ Guardian Legal Name
*
First Name
Last Name
Parent/ Guardian Preferred Name
Parent/ Guardian Phone Number
*
(###)
###
####
Parent/ Guardian Email
We'll be using this email address for the majority of our communication
Parent Guardian Birthdate
*
We need this for insurance coverage
MM
DD
YYYY
Parent/ Guardian Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What is the parent's/ guardian's preferred language?
*
Secondary Emergency Contact
*
First Name
Last Name
Secondary Emergency Contact Phone
*
(###)
###
####
PARTICIPANT GENERAL INFORMATION
**Please note** None of the general information answers influence your eligibility to attend. The inclusion criteria is only medically based and addressed in the next section.
Participant Birthdate
MM
DD
YYYY
Describe the participant in 5 words or less
Food Allergies
Please include the severity of the allergy
Are there any foods the participant does NOT like?
What are the participant's FAVORITE foods?
MEDICAL INFORMATION
Inclusion criteria: We cannot take anyone who has an external IV, i.e. PICC. (Ports are fine). If in active treatment your last few WBC counts must be stable; they can be low but not showing a downward trend.
Name of Primary Oncologist (Cancer Doctor)
Date of most recent visit to hospital
Diagnosis
Participant Age at Diagnosis
Date of Diagnosis
Treatment Stage
Just diagnosed/ treatment hasn't started
25% complete
50% complete
Completed
Treatment Completion Date (Chemo)
Treatment Completion Date (Radiation)
Course of Treatment
Please list any surgeries, rounds of chemo, etc.
Current Medications
Please include all medications. Name of drug, dose, time, special instructions, comments.
Any medication allergies? If yes, what is the allergic reaction?
Any recent health episodes in the last 3 months? If so, please explain briefly.
Any additional medical issues?
Any other information you want us to know about the participant's diagnosis, treatment or health?
Has the participant has the following challenges in the last year? Select all the apply.
These will cue us to get more information from you so we can brainstorm potential accommodations or be prepared for a potential need on the trail.
Toothaches
Infection, cold, flu, etc
Ingrown toenail
Back or joint injury
Fears/ phobias
Surgery
Antibiotic resistant infection, i.e. MRSO, VRE, CDIFF, ESBL
Frequent Headaches
Vision concerns
Hearing concerns
Breathing concerns
Heart concerns
Blood clotting concerns
Stomach or bowel concerns
NG/NJ/G tube device
Skin concerns
Diabetes
Emotional or mental health diagnosis
ADHD
Nightmares
Sleepwalking
Mobility concerns, splints, prosthetics
Orthodontic appliances
Wear contact lenses or eye glasses
Problems carrying a backpack
Bloody noses
Other
What types of activities does the participant like to do? And how often do they do them?
Shoe Size
Please note men's or women's shoe
Height
Weight
Please enter weight in lbs
Shirt Size
Brand & size of their favorite shirt.
Pant Size
Brand & size of their favorite pant.
Bra Size
Underwear Size
Once the medical team confirms you are eligible you can reserve your spot on the trip. This is done by holding your space with a credit card.
This trip is FREE to participants including all food, gear and transportation. However, due to the limited spaces available; IF YOU CANCEL for a non-medical reason your credit card will be charged the cost of the gear, up to $500.
Who is filling out this form?
Participant
Parent/ Guardian
How did you hear about us?
If someone referred you directly; such as your doctor, nurse or social worker, please tell us their name.
Does your teenager consent to participate in research and evaluation of the See You at the Summit Program?
*
The evaluation and research are three questionnaires; one at the beginning, one at the end, and one three months after, the trip. The participants will be compensated $100 for their participation. Participation is optional.
Yes
No
Do you agree to schedule a meeting between you, the clinic rep and SYATS staff?
*
This meeting will be to discuss medication. Selecting 'no' disqualifies the participant from attending.
Yes
No
Thank you!
PARTICIPANT INTAKE FORM
Please complete the form below
Participant Name
*
First Name
Last Name
Preferred pronouns
Phone
*
(###)
###
####
Email
*
Participant General Information
**Please note** None of the general information answers influence your eligibility to attend. The inclusion criteria is only medical based and addressed in the next section.
Birth Date
MM
DD
YYYY
Describe yourself in 5 words or less
Food Allergies
Please include severity of the allergy
Favorite Foods
There will be a person in charge of food who will be getting in touch to gather more info
Caffeine intake
What is your daily average consumption of caffeine?
Are there any foods you do NOT like?
How much school have you missed last year?
What has been your biggest struggle since your diagnosis? What have you missed the most?
In what ways have you noticed that your diagnosis has impacted you?
Have you had the following challenges in the last year? Select all that apply
These will cue us to get more information from you so we can brainstorm potential accommodations or be prepared for a potential need on trail.
Toothaches
Infection, cold, flu, etc
Ingrown toenail
Back or joint injury
Fears/ phobias
Surgery
Antibiotic resistent infection, i.e. MRSA, VRE, CDIFF ESBL
Frequent Headaches
Vision concerns
Hearing concerns
Breathing concerns
Heart concerns
Blood clotting concerns
Stomach or bowel concerns
NG/NJ/G tube device
Skin concerns
Diabetes
Emotional or mental health diagnosis
ADHD
Nightmares
Sleepwalking
Mobility concerns, splints, prosthetics
Orthodontic appliances
Wear contact lenses or eye glasses
Problems carrying a backpack
Bloody noses
Other
Other
What has surprised you about your cancer experience?
What is your current level of physical activity?
What type of activities do you like to do? How often do you do them?
Gear and Clothing Information
We will be outfitting you with the appropriate backpacking gear. For this reason, we need to know your clothing and shoe size. We ask that you get a tape measure and actually give us a few measurements. Thank you for taking the time to do this.
Shirt Size
Brand & size of your favorite shirt
Pant Size
Brand & size of your favorite pants
Bra Size
Underwear Size
Sock Size
Shoe Size
Height
Weight
Notes
Who is filling out this form?
Participant
Parent/ Guardian
SYATS
How did you hear about us?
If someone referred you directly; such as your doctor, nurse or social worker, please tell us their name.
Thank you!
