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Adult Information Submission
Adult Information Form
This form collects information from adults involved with the trip.
Adult Information
Name
*
First
Last
Name you go by
Gender
*
Male
Female
Other
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Date of Birth
*
YYYY slash MM slash DD
Email Address
*
Home Telephone
Cell Phone
*
Work Phone
AC Emp # (If Applicable)
Chapter & Agency Info
Chapter Location
*
Which chapter location are you in?
-- Select One --
Winnipeg
Other
Date of Flight
*
MM slash DD slash YYYY
Departure Location
*
-- Select One --
Winnipeg International Airport
Other Airport
What's your role?
*
-- Select One --
Group Leader
Chaperone
Sponsor Chaperone
Non-Group Adult
Unknown at this Time
Passport
Passport Number
*
Passport Expiry
*
DD slash MM slash YYYY
Passport Photocopy Upload
*
Must be valid 6 months post April, 2023
Max. file size: 50 MB.
Adult Particulars
Eye Colour
*
Hair Colour
*
Height
*
Weight (kg)
*
Scars or Birthmarks
Special Dietary Requirements / Special Meal Needs (Due to allergies, medical or religious reasons)
Medications
Simply hit the "+" icon to add a new item.
Organization/Group
This section is
not
for Dreams Volunteers
Organization/Group Name
If known, otherwise the planners will a assign you to a group
Health Care
Health Care ID
*
Enter your provincial Health Care Number(s) here. (Include both the 6 and 9 digits numbers).
Medical History & Insurance Info
For guardians or chaperones participating in the Dreams Take Flight (DTF) Program
: Please provide your medical history below.
If you answer "YES" to any of the following, please provide additional medical information in the responding textbox.
1) Are you currently taking any prescription medication?
*
--
Yes
No
What kind of medication?
If YES, please list your medications
2) Have you ever required or received medical treatment, or prescription medications for or had heart / cardiovascular condition or a stroke /cerebral vascular condition or an aneurysm?
*
--
Yes
No
Any other info?
3) In the past 6 months have you:
*
Received any new prescription medication or new medical treatment for any medical condition?
Had any prescription medication changed, reduced stopped or increased for any medical condition? (not including a change between brand name & generic brand)
Neither
What was this new prescription or medical treatment?
Which prescription medication changed?
4) In the past 5 years have you required or received medical treatment or taken prescription medication for or had any of the following:
*
Lung / Respiratory Condition
Diabetes (which is controlled by diet, medication, or with insulin)
Any test, investigation, or surgery recommended but not yet completed
Cancer or Leukemia
Blood disorder
Kidney disorder requiring dialysis or Liver disorder
Circulatory disorder of the arteries or veins
Pancreatic disorder
Muscle, bone, joint disorder (not arthritis)
Stomach or bowel disorder
Urinary disorder
Parkinson's Disease or seizures
High Blood Pressure (Hypertension)
Prostate disorder
Any other preexisting condition currently requiring medication?
None of the above
Please provide additional information on the conditions previously selected
5) Do you require assistance to sit upright and walk?
*
--
Yes
No
Any other info?
6) Do you have problems with bowel or urinary functions?
*
--
Yes
No
Any other info?
7) Do you require supplemental oxygen?
*
--
Yes
No
Any other info?
8) Do you require a feeding tube?
*
--
Yes
No
Any other info?
9) Do you use a wheelchair or other mobility device?
*
--
Yes
No
Any other info?
10) Do you use any special devices which you require all the time?
*
--
Yes
No
Any other info?
Emergency Contact Information
Must be valid from
4 AM Wednesday - 1 AM Thursday
.
Name
*
First
Last
Relationship
*
Home Telephone
*
Cell Phone
*
Adult Clothing
T-Shirt Size
*
Adult - Small
Adult - Medium
Adult - Large
Adult - X Large
Adult - 2X Large
Acknowledgement
Acknowledgements
*
I acknowledge that this is a 100% non-smoking day and 100% non-cellphone day)
I have completed my Child Abuse Registry Check or my Police Criminal Record Check
I acknowledge I am 100% ready to have some fun and make some magical memories for some very special children!
Phone
This field is for validation purposes and should be left unchanged.
Notifications
