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 Name
Last Name
Date of Birth
*
Please select a month
January
February
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Month
Please select a day
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Day
Please select a year
2025
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Year
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
City & State of Residence
*
Preferred method of contact
*
Phone
Email
Text
Closest Airport
Primary caregiver name (if applicable)
First Name
Last Name
Relationship to caregiver
How did you hear about The Journey Forward Project?
*
Doctor / hospital
Friend or family
Social media
Community organization
Other
Section 2: Diagnosis & Treatment
What type of cancer have you been diagnosed with?
*
Cancer stage (if known)
What treatments are you currently receiving or have received?
*
Chemotherapy
Radiation
Surgery
Immunotherapy
Hormone therapy
Other: _______
When did treatment begin?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expected treatment completion date (if known)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Has your medical team cleared you for travel following treatment?
*
Yes
Not yet
Unsure
Is your doctor comfortable with you traveling within the next 6–12 months?
*
Yes
Possibly with timing adjustments
Unsure
Section 3: Timing & Travel Logistics
Preferred timeframe for travel
*
Within 3 months
3–6 months
6–12 months
Flexible
How long of a stay would feel restorative?
*
Weekend (2–3 nights)
4–5 nights
One 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
Are stairs okay?
*
Yes
Prefer single-level accommodations
Do you require any of the following?
Wheelchair accessibility
Walk-in shower
Grab bars
Quiet/restful environment
Location near a medical facility
Other: _______
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?
What type of experience would you most enjoy?
Outdoor adventure
Cozy and restful
Family-focused
Romantic getaway
Flexible
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)
Upload a File
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Social media handles (optional) (We will never post anything without approval)
Section 8: Consent & Acknowledgement
If selected, are you willing to provide documentation of diagnosis/treatment?
*
Yes
No
Do you understand that submitting an application does not guarantee selection?
*
Yes
Do you consent to us sharing your story publicly (only with your approval)?
*
Yes
No
Maybe, please ask first
Submit Application
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