Skip to content
Above Header
Member Login
Login
Main Menu
Home
Get Involved
Menu Toggle
Donate
Menu Toggle
In Memory
Volunteer
Menu Toggle
Become a Member
Become a Volunteer
Become an Agency
Nominate a Child
Menu Toggle
Child Criteria
Adult Info Form
Our Stories
Sponsors
Events
Menu Toggle
Pub Night
Become An Event Volunteer
Flight Information
Other Events
Contact
Donate
Donate
Adult Information Submission
This form helps us collect information from adults who are going to be involved on the trip.
Adult Information
Name
*
First
Middle
Last
*AS THEY APPEAR ON YOUR PASSPORT
Preferred Name
Gender
*
Male
Female
Other
Address
*
Street Address
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
*
MM slash DD slash YYYY
Email Address
*
Primary Telephone
*
Alternate Phone
*
AC Emp # (If Applicable)
Chapter & Agency Info
Chapter Location
*
Which chapter location are you in?
-- Select One --
Vancouver
Date of Flight
*
MM slash DD slash YYYY
Departure Location
*
-- Select One --
Vancouver International Airport
Canadian Passport
Passport Number
*
Passport Expiry
*
MM slash DD slash YYYY
Passport Photocopy Upload
*
Must be valid 6 months post October 3, 2024
Drop files here or
Select files
Accepted file types: pdf, jpg, jpeg, png, Max. file size: 293 MB.
Criminal Record Check
*
Please upload a copy of your CRC/VSS Checks (Police Checks)
Drop files here or
Select files
Accepted file types: pdf, jpg, jpeg, png, Max. file size: 293 MB.
Adult Particulars
Eye Colour
*
Hair Colour
*
Height (cm)
*
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
Health Care
Health Care ID
*
Enter your British Columbia Health Care Number here.
Please upload the Federal QR Code for proof of COVID19 Vaccination status
*
Drop files here or
Select files
Accepted file types: pdf, jpg, jpeg, png, Max. file size: 293 MB.
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?
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 12 months (6 months for high blood pressure) 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
*
Primary Telephone
*
Alternate Phone
*
Adult Clothing
T-Shirt Size
*
Ladies - Small
Ladies - Medium
Ladies - Large
Ladies - X Large
Ladies - 2X Large
Mens - Medium
Mens - Large
Mens - XLarge
Mens -XXLarge
Mens - XXXLarge
Acknowledgement
Acknowledgements
*
I acknowledge that this is a 100% non-smoking day
I acknowledge that this is a 100% non-cellphone day (Only as required for Day of Flight/Dreams Take Flight. NO Personal/Work Use)
I have completed my CRC / VSS checks (Police checks)
Name
This field is for validation purposes and should be left unchanged.