Contact InformationAll fields are required unless noted.Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Cell Phone(Required)Birthdate(Required) MM slash DD slash YYYY Age(Required)Please enter a number from 1 to 100.This field is hidden when viewing the form(old)I am registering to participate as a… Patient Survivor Caregiver Co-Survivor Healthcare Professional Other I am registering to participate as a… (Select all that apply)(Required) Patient Survivor Caregiver Supportive Loved One Medical Professional Nonprofit Professional Other (Please specify this response in the question below) If you selected 'Other', please specify:Have you attended Young Adult Cancer Camp before? (Select all that apply)(Required) Yes, in 2022 Yes, in 2023 Yes, in 2024 Nope! This is my first year. Gender DisclosureWe ask this question to assist us in assigning you to a cabin you will feel most comfortable in. You will have the opportunity to provide further details about your preferred cabin later in the form.Gender(Required) Cisgender Woman Cisgender Man Non-binary Transgender Woman Transgender Man Other Pronouns(Required) She/Her He/Him They/Them Other T-Shirt Size(Required)X SmallSmallMediumLargeX LargeXX LargeXXX LargeRace/Ethnicity(Required) American Indian or Alaskan Native Asian or Pacific Islander Black/African American Hispanic or Latino or Spanish Origin of any race Multiracial or Biracial Native Hawaiian or Other Pacific Islander Middle Eastern White Race and Ethnicity Unknown Prefer not to disclose Other Travel InformationPlease Select One(Required) I will be arriving by car I will be flying I don’t know yet IMPORTANT: Linens & TowelsDue to the unavailability of a linen rental service this year, and in an effort to keep registration fees at a minimum, we will only be providing linens/towels to campers who are flying in for the weekend. If you are arriving by car, you will be responsible for bringing your own sheets, blankets, pillows, and towels. We sincerely apologize for this inconvenience.Emergency ContactEmergency Contact Name(Required) First Last Emergency Contact Relationship(Required)Emergency Contact Email(Required) Emergency Contact Primary Phone(Required)Emergency Contact Secondary PhoneHave a song you want added to our YACC 2025 playlist? List it here!PreferencesDietary Restrictions(Required) Gluten Free Dairy Free Vegan Vegetarian Other No Restrictions Dietary Restrictions – OtherPreference on Bunkmates?(Required) Yes No Please Note: We can’t guarantee matching bunkmates but will do our best to match you with who you request.If so, list their names and relationships:What would you consider yourself when it comes to sleeping?(Required) Early bird (bed before 10pm/up early) Night owl (bed between 10pm-midnight/sleep in) Nocturnal Creature (bed after midnight/up whenever I feel like it) Not a concern, I go with the flow Please note, we will do our best to accommodate based on selections but we will not guarantee a perfect match.Are you comfortable being in a mixed gender cabin?(Required) Yes No Elephants and Tea and YASU are strongly committed to the comfort and safety of all of our participants at Young Adult Cancer Camp. If you have any concerns or would like to discuss the possibility of mixed-gender rooms, please contact lisa@elephantsandtea.org or lindsey@yasurvivors.org. Elephants and Tea and YASU will not have final information on bunking options until registration is complete.Will you require a specific bunk for medical reasons?(Required) Yes No If Yes, Please Explain.ADA AccommodationsElephants and Tea and Young Adult Survivors United, in partnership with Camp Kon-O-Kwee Spencer, are committed to making our events accessible to all individuals and will work to make every effort to accommodate all requests as specified by the Americans with Disabilities Act. If you have a disability and anticipate needing accommodations while at Young Adult Cancer Camp, please indicate your needs below. (Please provide specific details so we can best accommodate your needs, i.e. Wheelchair Accessibility, Service Animal, Assisted Listening Devices/ASL interpretation, etc.) If you require additional or full-time support, please plan accordingly and bring your own caregiver as you will not have the option of staff or your fellow campers for consistent assistance.Please specify your ADA needsMedical HistoryCaregivers, please enter “N/A” for these questions if they do not apply to you.What form of cancer were you/someone you care about diagnosed with?(Required)Do you wish to share your diagnosis on your camp name tag?(Required)YesNoAge of Diagnosis(Required)Any other health issues we should be aware of?(Required)Are you currently in treatment? If so, what treatment?(Required)Medical Center(Required)Oncologist Contact Name(Required)Oncologist Contact Phone number(Required)Please list current medications including dosage and frequency.Click the + to add a new line item for medication/dosage.MedicationDosage/Frequency Add RemovePlease list any allergies you have (food, environmental, and medicine).Do these allergies require use of an epipen? Yes No ASSUMPTION OF RISK & RELEASE OF LIABILITY(Required)I acknowledge the highly contagious nature of infectious disease, including but not limited to COVID-19, and the risk that I may be exposed to or contract COVID-19 by attending Young Adult Cancer Camp (YACC). I understand and acknowledge that such exposure or infection may result in serious illness, personal injury, psychological injury, pain, suffering, temporary or permanent disability, death and/or financial loss. I understand that Elephants and Tea and Young Adult Survivors United (YASU) cannot guarantee that I will not become infected with COVID-19 or any other infectious disease due to attending YACC, and that attending may increase the risk of contracting COVID-19 or any other infectious disease. I also acknowledge that this risk may result from or be compounded by the actions, omissions, or negligence of others, including Elephants and Tea and YASU employees and volunteers. Notwithstanding these risks, I acknowledge that I am a voluntary participant of YACC, with full knowledge of the precautionary measures in place and the risks involved. I acknowledge that I derive personal satisfaction and a benefit by virtue of my participation and attendance at YACC 2025. BASED ON THE FOREGOING, I hereby release, waive, and forever discharge any and all liability, claims and demands whatever kind or nature against Elephants and Tea and YASU, Camp Kon-o-Kwee Spencer, and any other third parties involved in the planning and execution of YACC 2025, including in each case, without limitation, their directors, officers, employees, volunteers and agents (the “released parties”), either in law or in equity, to the fullest extent permissible by law, including but not limited to damages or losses caused by the negligence, fault or conduct of any kind on the part of the released parties, including but not limited to serious illness, personal injury, psychological injury, pain, suffering, temporary or permanent disability, death and/or financial loss, which I, my heirs, assignees, next of kin and/or legally appointed or designated representatives, may have or which may hereinafter accrue on my behalf, which arise or may hereafter arise from my participation at YACC 2025. This Assumption of Risk & Release of Liability (the “Release”) is intended to be as broad and inclusive as is permitted by law. If any part of the Release is held to be invalid or legally unenforceable for any reason, the remainder of this Release shall not be affected thereby and shall remain valid and fully enforceable. I have been fully informed of the risks associated with in-person attendance and give my voluntary consent in agreeing to the Assumption of Risk & Release of Liability as my free act and deed, with full intention to be bound by the same, and free from any inducement or representation. I ConsentDRUG & ALCOHOL POLICY(Required)By attending camp, you agree to the following policy set forth by the YMCA camp: Alcohol, recreational use of marijuana (see below for medical marijuana guidelines), and other drugs are not permitted on the YMCA campus. Medical marijuana is legal in the state of Pennsylvania under strict parameters. YMCA Camp Kon-O-Kwee Spencer and the YMCA of Greater Pittsburgh does allow overnight camp guests to have these medicines, but all participants must follow the rules below. Medical marijuana is only able to be used by people who have medical needs and have a registered card. Participants must have their registered card available at any time. All medications, including medical marijuana, must be kept locked and secured at all times. They are the responsibility of the adult they are prescribed to. All medications, including medical marijuana, must be labeled properly in the original container with the contents and the person who is responsible. Smoking is not permitted in any buildings at any time. If possible, please only bring non-smoking medications. If smoking is the only option, please use outside space away from housing and program spaces. All medications, including medical marijuana, are not to be used by any person other than the person who it is prescribed to. I ConsentPhotography and Recording Release(Required)Acknowledgement and Consent – I consent to the video or audio recording and/or photography, by Elephants and Tea + Young Adult Survivors United, its representatives or licensees or any other party authorized by Elephants and Tea + Young Adult Survivors United, of my name, likeness or other personal characteristics (e.g., voice, biographical information, or other identifiable information), and/or my property, including any exhibit or presentation materials, in connection with my attendance at Young Adult Cancer Camp. I also consent to the reproduction, publication, distribution, exhibition, display or use of any such images or recordings, with or without my name, company name, or with a fictitious name, by Elephants and Tea + Young Adult Survivors United or its successors, assigns or licensees, in connection with its operations, products and services, or any other legally-permissible uses chosen by Elephants and Tea + Young Adult Survivors United such as public relations, commercial uses, advertising, and publishing (including in electronic form on the Internet), in all manners, in any current or future medium or format, throughout the world. I acknowledge that Elephants and Tea + Young Adult Survivors United is not obligated to use or exercise any of these rights. I further acknowledge that I have the authority to grant this nonexclusive license and that doing so will not violate the rights of anyone else. I recognize that Elephants and Tea + Young Adult Survivors United, as the program producer, will be the copyright owner of all photographs, video/audio recordings and all media, products or content subsequently generated from those materials, and I waive any right to royalties or other compensation arising from or related to their creation or use. I understand that images and recordings may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness or personal information appears. I further agree not to record or broadcast any portion of the conference without the prior written consent of Elephants and Tea + Young Adult Survivors United, unless I have validly registered for Young Adult Cancer Camp as a member of press and received press credentials, in which case I agree to abide by the terms of the Young Adult Cancer Camp’s Media Policy. Still photography is permitted for non-commercial purposes with the permission of those being prominently photographed. I understand that noncompliance with this policy is grounds for exclusion from this and future events. I also confirm that, if I am registering as a sponsor and to the extent any presentation or sponsored materials I utilize will include third-party material, I have obtained permission for its use consistent with the scope of this license. I ConsentPaymentCamp Registration Price: CouponIf you have a coupon for this event, please enter it here. Total PaymentCredit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Card Number Exp Date Expiration Date Security Code Security Code Cardholder Name VerificationEmailThis field is for validation purposes and should be left unchanged. Δ
