Youth Cancer Trust Holidays Application Form

Youth Cancer Trust Holiday Application Form

If you are eligible for a Youth Cancer Trust Holiday, please complete and submit the following full application form. If you are unsure, please complete the enquiry form or contact us on 01202 763591. Once we have received your submitted form, we will be in touch to arrange the details of your holiday.
Full Name:*

First NameMiddle NameLast Name
Date of Birth:*

DayMonthYear
Date
Current Address:*

Street Address

Street Address Line 2

CityCounty

Postal CodeCountry
Email Address:*
Telephone Phone Number:*

Area CodePhone Number
Facebook:
Which is the best way to contact you to confirm holiday details?*

By EmailBy MobileBy PostFacebook messenger
Have you been on a Youth Cancer Trust holiday before?*

YesNo
If you have been on a Youth Cancer Trust holiday before and answered yes to the last question, what date was the holiday?
Your Parent / Guardian / Next of Kin details in case of an emergency
Full name of Parent / Guardian / Next of Kin:*

First NameLast Name
Parent / Guardian / Next of Kin Phone Number*

Area CodePhone Number
Medical Information
Please confirm your GP or Consultant has agreed you are fit to come on a Youth Cancer Trust holiday.*

YesNo
Name of GP:*

First NameLast Name
Name of GP's Surgery Practice:*
Phone Number of Surgery / Practice:*

Area CodePhone Number
Emergency Out of Hours Surgery Phone Number:*

Area CodePhone Number
Name of Consultant or Cancer Nurse Specialist:*

First NameLast Name
Name of Hospital or Treatment Centre:*
24 hour Telephone Number for Medical Advice (in an emergency):*

Area CodePhone Number
Cancer Diagnosis Details:*
Date First Diagnosed:*
Has the applicants' treatment finished?*

YesNo
If you answered yes to the last question, when did the treatment finish?

MonthDayYear
Date
Current On-going Medical Status

PLEASE NOTE - To meet the criteria for a Youth Cancer Trust holiday, the applicant will need to be able to self medicate.

Please List Your Current Medicines:

	Medication	Dose / When	Administered e.g orally
1
2
3
4
5
6
7
8
9

Allergies:

	What happens?	Treatment?
Allergy
Allergy
Allergy
Allergy

Current Medical Issues:

	Comments / Suggestions?	When last experienced?
Issue / Problem
Issue / Problem
Issue / Problem
Issue / Problem

Current On-going Needs:

	Details / Suggestions / Information?
What type of line?
Is the applicant ok to shower / bath?
Is the applicant ok to swim?
Any additional infomation?

Daily Living:*

	Details / Suggestions / Information?
Does the applicant have any problems communicating verbally?
Does the applicant have any hearing or visual impairment?
Does the applicant have any mobility issues?
Does the applicant have any breathing problems such as Asthma?
Does the applicant have unstable blood sugars? If so please provide requirements
Does the applicant have any special dietary requirements? (e.g. vegetarian)
Does the applicant have any food allergies? If yes please be very specific
Are there any foods which the applicant will not eat?
Does the applicant tire easily from walking short distances?
Does the applicant have difficulties walking upstairs? (Please note that the bedrooms at Tracy Ann House are on the first floor)
Does the applicant require a wheelchair at all? (YCT has a mobility scooter and a wheelchair)
Any other information?

Mental Health:*

	Details / Suggestions / Information?
Has the applicant been diagnosed with any behavioural / emotional issues which might affect their time at Tracy Ann house? If so, how is this behaviour managed?
Has the applicant been diagnosed with ANY behavioural disorders such as ADD or ADHD?
Has the applicant been away from home before?

HOLIDAY DATES

Please note - Youth Cancer Trust holidays take place from Mondays to Fridays (not weekends), all year round.
First Choice of Holiday Date - Our holidays run from Mondays to Fridays (not weekends). Please choose any Monday as your preferred holiday date.*
In case your first choice is already fully booked, please enter your second choice of holiday date - Our holidays run from Mondays to Fridays (not weekends). Please enter any Monday as your preferred holiday date.*
Companion's Details:*

FriendBrotherSisterPartnerI want to come on my own
Companion's Name

First NameLast Name
Companion's Date of Birth

DayMonthYear
Date
Companion's Address

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
Companion's Mobile Number:

Area CodePhone Number
Name of Companion's Parent / Guardian:

First NameLast Name
Companion's Parent / Guardian Phone Number:

Area CodePhone Number

EMERGENCY MEDICAL TREATMENT CONSENT
In the event of a need for emergency medical treatment and parents/guardians/next of kin cannot be contacted. I (parent/guardian/next of kin) give permission to the staff of Youth Cancer Trust Holidays to give consent for such treatment for the applicant on my behalf:*

First NameLast Name
Please provide E-Signature of Parent / Guardian / Next of Kin named above:*

Clear
The applicant's GP has agreed that the applicant is fit to come on a Youth Cancer Trust holiday. A parent / guardian / next of kin E-Signature is required if the applicant is under 18.

Clear
Applicant's E-Signature if over 18

Clear
YOUTH CANCER TRUST HOLIDAY ACTIVITIES

Activities are optional and if the applicant does not feel well enough to take part, they can either accompany the group or stay at the house. Activities can include horse riding, go karting, water sports, sailing amongst others
Are any activities to be avoided? *
PARENT / GUARDIAN CONSENT - IF APPLICANT IS UNDER 18
If applicant is under 18. “To the best of my knowledge, at this time, this is a true and accurate description of my child’s needs”

First NameLast Name
Parent / Guardian E-Signature (if applicant is under 18)

Clear
PUBLICITY

To encourage funding and support of the Youth Cancer Trust we sometimes use photos of the groups during their holidays and make reference to the applicant's stay at Youth Cancer Trust for press releases and other promotional / publicity materials. We may include their first name (not surname), age and the area they live (not address) E.g. Vicky, aged 16 from Dorset.
Please indicate if you (the applicant) are happy to be part of any publicity material for Youth Cancer Trust?*

YESNO
Sometimes a photograph will be used more than once in marketing materials. Please indicate if you are happy for this to happen?*

YESNO
Has the applicant any criminal convictions (apart from road traffic offences)?*

YESNO
AGREEMENT - We understand that sometimes holidays have to be cancelled at short notice due to ill health. However, if you have to cancel due to work or other activities, please do give us as much notice as possible. These holidays cost the charity substantial amounts of money so please allow us plenty of time to offer your place to someone else.
Person completing form*

First NameLast Name
Relationship to applicant?
Agreement signed:*

Clear
Today's Date*
Where did you hear about the Youth Cancer Trust?
EQUAL OPPORTUNITIES
Is the applicant?*

MaleFemale
What is the applicant's ethnic background?*

Black CarribeanBlack AfricanBlack OtherWhiteChineseIndianBangladeshiPakistaniPrefer not to state
TRANSPORT PLANNING

Please read and complete the following carefully: Please book your travel tickets at least 14 days in advance to obtain preferential rates and then confirm all of your travel arrangements with the office (01202 763591 or admin@yct.org.uk or via our Facebook page). If you need help with your travel arrangements, please let us know as soon as possible at the time of booking your holiday. YCT holiday guests and companions are asked to arrive after 2pm on the Monday and to leave Tracy Ann House by 11am on the Friday if possible. We understand if train times do not permit this.
How will the applicant get to and from Tracy Ann House in Bournemouth?*

The applicant will be driving to and from YCT in their own carThe applicant will be given a lift to & from YCT by a parent / guardianThe applicant will be travelling by trainThe applicant will be travelling by planeNot sure of travel arrangements yet
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS FORM

The completion of this form is a legal requirement for Youth Cancer Trust. Please Note ** Youth Cancer Trust does not disclose personal data to third parties. Personal data is kept confidential and only used for the purposes of arranging your holiday and keeping in touch with you.If you have any questions relating to this form or Youth Cancer Trust holidays please telephone 01202 763591 and we will be happy to help.
If you have anything you would like to add, please do so here... PLEASE REMEMBER TO CLICK 'SUBMIT' TO SEND YOUR COMPLETED FORM.
Should be Empty:

	Details / Information / Comments
Allergies
Special dietary needs
Any other Information

Youth Cancer Trust Holiday Application Form

Your Parent / Guardian / Next of Kin details in case of an emergency

Medical Information

Current On-going Medical Status

HOLIDAY DATES

EMERGENCY MEDICAL TREATMENT CONSENT

YOUTH CANCER TRUST HOLIDAY ACTIVITIES

PARENT / GUARDIAN CONSENT - IF APPLICANT IS UNDER 18

PUBLICITY

EQUAL OPPORTUNITIES

TRANSPORT PLANNING

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS FORM