Base2Summit Program Application CommentsThis field is for validation purposes and should be left unchanged.Welcome to the Base2Summit registration! Your application is the basics we need to get started on placing you on a B2S week. Your information is autosaved as you enter it. If you do not complete this application in one sitting, select the “Save and continue later” option at the bottom of the form and a link for will populate. Please note, this link is only valid for 30 days. You must enter your email to have the link sent to you, we cannot access the link for you. Once sent, If you do not see the emailed link, check your spam folder. If you get stuck at any point, feel free to email madison@chscf.org for assistance Once you’ve completed the registration, the “Submit” button at the bottom of the application will light up. Please note ALL *stared* sections must be filled out before “submit” is possible. If after starting this application, you find that you do not have the time to complete it, DO NOT EXIT FORM WITHOUT SAVING! Your information will be lost if you don't save it! Follow the prompts to save and complete later. General Information:Full Name (as it appears on your drivers license)(Required) First Last What name should we call you?Date of Birth(Required) MM slash DD slash YYYY Gender(Required)Choose OneMaleFemaleNon-BinaryPrefer not to answerCell Number(Required)Email(Required) Full Address(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Occupation(Required)Emergency Person:Name(Required) First Last Cell Number(Required)Email(Required) Relationship to Applicant(Required)T-shirt Size(Required)Unisex sizesChoose OneXSSMLXL2XL3XLBest way and/or time to reach you(Required)Let’s get to know you a bit:How did you hear about Base2Summit?(Required)Have you been to other survivorship programs? Tell us where and when.(Required)Do you have any dietary needs you’d like us to honor? Please let us know if this is an allergy or preference.(Required)Do you have any physical limitations we should be aware of?(Required)Please make us aware of any emotional needs we could lend support to during B2S.(Required)Is there anything you’d like us to know upfront that would be helpful in maximizing your experience at B2S?(Required)Base2Summit has fall and summer programs. Both are founded in outdoor adventures but highlight Michigan's beauty in different ways. Please select your preference.SummerFallFirst AvailableHealthcare Providers:Primary Care:Name(Required) First Last Phone Number(Required)Email Cancer Center:Name(Required)(Required) City State / Province / Region Oncologist:Name(Required) First Last Phone Number(Required)Email When was your last oncology follow-up?(Required) MM slash DD slash YYYY Health Insurance: (Upload copy of card)(Required) Drop files here or Select files Max. file size: 80 MB. Health History Information:Primary cancer diagnosis:(Required)Year of original diagnosis:(Required)Is there a secondary cancer diagnosis or any medical conditions caused by your primary cancer?(Required)Without including every detail, give us the basics of your cancer treatment.(Required)Chemo, Radiation, Surgery, with most recent dates includedAre you currently in treatment of any kind? Tell us about it.(Required)Are you allergic to anything? (Environmental, food and/or medications) If yes, please list here.(Required)Have you had any non-cancer related injuries or conditions that would affect your ability to participate in outdoor adventure activities?(Required)Are your immunizations up to date (including tetanus)?(Required)Choose OneYesNoAre you diabetic? If yes, how is it treated?(Required)Have you had seizures? If yes, type and frequency.(Required)Have you ever fainted? If yes, frequency and cause, if known.(Required)Do you have frequent headaches that affect your daily routines? If yes, how often?(Required)Do you have asthma or shortness of breath? If yes, how is it treated?(Required)Base2Summit will likely include (but not limited to) biking, hiking and water sports (ie:kayaking SUP, swimming, boating, sailing). Do you have any fears, limitations or concerns we should be aware of?MedicationsList all current mediations (both prescription and non prescription):(Required)Create a list below or upload a typed list. If you're not on medications, please type NONE or if you uploaded a list type UPLOADED. Add RemoveUpload List of Medications Drop files here or Select files Max. file size: 80 MB. Authorizations:Link to Base2Summit policy on tobacco, alcohol and cannabisBase2Summit policy on tobacco, alcohol and cannabis(Required) I consent to the Base2Summit policy on tobacco, alcohol and cannabis.Link to participant release agreementParticipant release agreement(Required) I consent to the participant release agreement.Copy of medical advance directive (If Applicable) Drop files here or Select files Max. file size: 80 MB.
