Vacation Application Form for Cancer Patients & Caregivers

Vacation Application Form for Cancer Patients & Caregivers - The Journey Forward Project

Apply to receive a supportive vacation offered by our nonprofit organization.
Section 1: Basic Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
City & State of Residence*
PhoneEmailText
Closest Airport
Primary caregiver name (if applicable)

First NameLast Name
Relationship to caregiver
Doctor / hospitalFriend or familySocial mediaCommunity organizationOther
Section 2: Diagnosis & Treatment
What type of cancer have you been diagnosed with?*
Cancer stage (if known)
ChemotherapyRadiationSurgeryImmunotherapyHormone therapyOther: _______
When did treatment begin?*

MonthDayYear
Date
Expected treatment completion date (if known)

MonthDayYear
Date
YesNot yetUnsure
YesPossibly with timing adjustmentsUnsure
Section 3: Timing & Travel Logistics
Within 3 months3–6 months6–12 monthsFlexible
Weekend (2–3 nights)4–5 nightsOne week
How many guests would be joining you?*
Who would you like to bring? (Spouse, children, caregiver, friend, etc.)
If children are traveling, please list their ages.
Section 4: Comfort & Accessibility Needs
Do you have any mobility limitations? If so, please explain
YesPrefer single-level accommodations
Wheelchair accessibilityWalk-in showerGrab barsQuiet/restful environmentLocation near a medical facilityOther: _______
Will you be bringing any medical equipment that needs accommodation?
Any food allergies or dietary restrictions?
Section 5: What Brings You Joy?
What do you enjoy doing in your free time?
What would make this vacation feel truly special to you?
Outdoor adventureCozy and restfulFamily-focusedRomantic getawayFlexible
Are there any activities you would love included if possible? Examples: Bike rental, Massage, Restaurant gift card, Ski passes, Horseback riding, Sporting events, Concerts/shows, Other: _______
Section 6: Your Story
Please share a little about your journey.
How has cancer impacted your daily life or family?
What would having something to look forward to mean for you right now?
Is there anything else about your situation that you would like us to understand when considering your application?
Section 7: Additional Information
Emergency Contact Name*
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Upload a photo (optional)

Cancelof
Social media handles (optional) (We will never post anything without approval)
Section 8: Consent & Acknowledgement
YesNo
Yes
YesNoMaybe, please ask first
Should be Empty:

Vacation Application Form for Cancer Patients & Caregivers - The Journey Forward Project

Section 1: Basic Information

Section 2: Diagnosis & Treatment

Section 3: Timing & Travel Logistics

Section 4: Comfort & Accessibility Needs

Section 5: What Brings You Joy?

Section 6: Your Story

Section 7: Additional Information

Section 8: Consent & Acknowledgement