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*
Address*
Street Address Address Line 2 City 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?
Date of Flight*
MM slash DD slash YYYY
Departure Location*
What's your role?*
Passport
Passport Number*
Passport Expiry*
DD slash MM slash YYYY
Passport Photocopy Upload*
Must be valid 6 months post April, 2023
Max. file size: 293 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?*
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?*
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?*
Any other info?
6) Do you have problems with bowel or urinary functions?*
Any other info?
7) Do you require supplemental oxygen?*
Any other info?
8) Do you require a feeding tube?*
Any other info?
9) Do you use a wheelchair or other mobility device?*
Any other info?
10) Do you use any special devices which you require all the time?*
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*
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!
Name
This field is for validation purposes and should be left unchanged.

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Dreams Take Flight | Winnipeg

Dreams Take Flight stretches children’s minds. As poet Oliver Wendell Holmes wrote, “One’s mind, once stretched by a new idea, never regains its original dimensions.”

Adult Information Submission

Adult Information Form

Adult Information

Chapter & Agency Info

Passport

Adult Particulars

Organization/Group

Health Care

Medical History & Insurance Info

Emergency Contact Information

Adult Clothing

Acknowledgement

Dreams Take Flight | Winnipeg

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