EmailMeForm
BrainWAVE Registration Form - Vancouver Zoo
Please complete the fields below to register for the Vancouver Zoo activity on Saturday June 17th. We will contact you as soon as possible to confirm your registration. Please note that the number of places is limited. RSVP by June 9th
Last Name:
*
Parent(s) or Guardian(s) Names:
*
First
Last
Parent(s) or Guardian(s) Names:
First
Last
Telephone:
*
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Email:
*
Address:
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
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Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
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Monaco
Montenegro
Netherlands
Norway
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Portugal
Romania
San Marino
Serbia
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Slovenia
Spain
Sweden
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United Kingdom
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Indonesia
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Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
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