EmailMe Form - BrainWAVE Registration Form - Fort Edmonton Park

BrainWAVE Registration Form - Fort Edmonton Park

Please complete the fields below to register for the Fort Edmonton Park activity on Saturday June 24th. We will contact you as soon as possible to confirm your registration. Please note that the number of places is limited. RSVP by June 12th

Last Name: *
Parent(s) or Guardian(s) Names: *
First Last
Parent(s) or Guardian(s) Names:
First Last
Telephone: *
### - ### - ####
Email: *
Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Name of child with a brain tumour (under 19 yrs of age): *
First Last
Child's Date of Birth: *
MM / DD / YYYY
Brain Tumour Type:
Malignant
Non - Malignant
Mixed Grade
Unknown/Waiting on Pathology
Name of sibling who will be attending (must be under 19 years of age):
First Last
Age
Name of sibling who will be attending (must be under 19 years of age):
First Last
Age
Name of sibling who will be attending (must be under 19 years of age):
First Last
Age
Name of sibling who will be attending (must be under 19 years of age):
First Last
Age
Name of sibling who will be attending (must be under 19 years of age):
First Last
Age
Total number of family members INCLUDING the child with a brain tumour who will be attending the event (parents and siblings only)
Please specify any dietary restrictions:
Please indicate any mobility restrictions:
The following information helps us to best plan programs and services for everyone affected by a brain tumour. This section is optional and all information is kept confidential.
How did you hear about us?
Advertising
Poster
Family Member/Friend
Online
Referral from Physician/HCP/Treatment Center
Other
I would like to share my family's story in the media and/or online on the foundation's website.
Yes
No
I give permission to the BTFC to use our photos or videos taken on this day.
Yes
No