SC Crew Membership Application

SC Crew Member Application

Are you ready to join a fun, supportive and unique group, exclusively for teens and young adults with sickle cell disease? (Ages 14.5-20)
Name of Person Completing Application*

First NameLast Name
Relationship to the member:*

Parent/guardianSelf (over 18)Social WorkerFamily MemberOther
Phone Number*

Area CodePhone Number
Email*

Confirmation Email
Member Information
Name of Member:*

First NameLast Name
Birth Date:*

MonthDayYear
Age:*
Gender:*
T-shirt Size:

Adult X-SmallAdult SmallAdult MediumAdult LargeAdult X LargeAdult 2XOther
Sweatshirt/Hoodie Size:

Adult X-SmallAdult SmallAdult MediumAdult LargeAdult X LargeAdult 2XOther
School:
Grade:*
Member's cell phone number:*

Area CodePhone Number
Does cell phone accept texts?*
Member's Email:
example@example.com
What is the best way to communicate with member?

Phone CallText messageEmailOther
Has member attended Camp Crescent Moon before?*
Has member attended Camp Gibbous before?*
Parent/Guardian Information
Parent/Guardian #1:

First NameLast Name
Relationship to Member:
Phone Number:

Area CodePhone Number
Phone Type:
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian #2:

First NameLast Name
Relationship to Teen:
Phone Number

Area CodePhone Number
Phone Type:
Address

Street Address

Street Address Line 2

CityState

Zip Code
How confident are you that member is ready to transition to adult care?*
Has the pediatric center where member currently receives care, prepared them for the transition to adult care?*
Medical Information
What type of sickle cell disease does member have?*

Sickle Cell Anemia (SS)Sickle C Disease (SC)Sickle D Disease (SD)Sickle E Disease (SE)Sickle Beta 0 (zero) ThalassemiaSickle Beta + (plus) ThalassemiaUnknownOther
Where does member receive their Sickle Cell Disease Care?*
Physician:*

First NameLast Name
Physician Phone Number:*

Area CodePhone Number
Physician Type:*
What Type of Medical Insurance does member have:

MediCalMedicareCCSIEHPGHPPKaiserHMOPPOMilitaryUnsureOther
Emergency Contact Information
Emergency Contact:*

First NameLast Name
Emergency Contact Phone:*

Area CodePhone Number
Relationship to Member:*
Additional Information
Is member interested in being assigned a mentor?*
Please share what qualities, interests, and/or experience member would like to see in a mentor. (Ex: a mentor with SCD, an outgoing mentor, a mentor who is in college, etc.)*
Is member comfortable attending in-person activities or do they prefer to be a virtual member?*

In-Person MemberVirtual Member
What means of transportation would member use to get to the Monthly Meet-Ups at our office in Ontario?*

Drop off/Pick Up by parentDrive to OntarioPublic transportation (Bus/Train)Uber/Lyft RideMember needs help with transportationOther
What is member hoping to learn or gain from being a part of the SC Crew Program?*
What topics is member most interested in learning about at our monthly Meet-Ups?

How to transition to adult care properlyNavigating the Emergency RoomSickle Cell Disease EducationLife SkillsMoney ManagementResume BuildingHow to get your Driver's LicenseAnxiety, Depression, GrievingOther
What fun outings is member most interested in participating in?

BowlingSkatingMoviesTop GolfMiniature GolfAmusement Parks (Six Flags, Knott's Berry Farm, etc.)Laser TagCollege Campus ToursOther
College Campus Tours- Please list any campuses in CA that you are interested in visiting:
Due to COVID-19, we want to ensure the comfort of all members and staff. Please answer the following questions.
COVID-19 Testing: Is member comfortable with testing when needed for events or meetings with our SC Crew Program? (Please note: Testing would be required for all staff and members)*

YesNoOther
COVID-19 Vaccination Status: Is member COVID-19 vaccinated?*

YesNoOther
Please upload member's COVID-19 vaccination record:

Browse Files

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Submit your application with the red button below. We will follow up with you shortly*

I agree
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SC Crew Member Application

Member Information

Parent/Guardian Information

Medical Information

Emergency Contact Information

Additional Information

Due to COVID-19, we want to ensure the comfort of all members and staff. Please answer the following questions.