Application Form

Complete the full application form.

Please complete the application form and then expect a call back from us within 2 weeks.

During the phone call we will establish what your needs and wishes are:

Sign up for online community only
Sign up for holiday
Sign up for holiday and online community
Signpost to other services as we can’t provide you with what you need

Things you need to know

We offer both holidays and online support. You can apply for either or both.

We call our young people ‘ GUESTS’ .
Guests are able to bring a COMPANION with them on holiday (sibling, friend, partner of a similar age) they are called COMPANION guests.
We provide online support for GUESTS only
Staff are not medically trained
We have confidentiality and safeguarding policies
We operate flexibly in office hours 8.30 – 5. 30. When there is an evening or weekend activity we work at the hours specific on the event.

Application Form

Who’s completing the form:

Young Person completing themselfParent /GuardianOther relativeHealth professional

If not a young person please give name and background info

Guest details and information

Personal Information

Name

Preferred name

Date of Birth

GenderMaleFemaleTransgenderNon-binary/non-conformingPrefer not to respond

Upload a photo

Please upload a photo of yourself so we can recognise you if we need to collect you and so our chef knows who you are if you have any particular dietary requirements.

Contact Details

Street Address

Street Address Line 2

City

County

Postal Code

Country

Contact Number

Email Address

How do you prefer to be contacted

Email (we will need to email you with information)FacebookTextWhatsAppPhone call

Emergency Contact

We take the wellbeing of our guests very seriously. Should we have any concerns about your health and wellbeing whilst participating in our online programme we request that you can please provide us with an emergency contact. If you are under 18 this must be your parent/ guardian.

Primary Contact

Name of Emergency contact

Relationship to guest

Mobile number or landline

Secondary Contact

Name of Emergency contact

Relationship to guest

Mobile number or landline

Equal Opportunities

Guest considers their ethnic background to be?

Black CarribeanBlack AfricanBlack OtherWhite caucasianChineseIndianBangladeshiPakistaniPrefer not to respond

Guest's Religion

BuddhismChristianityJehovah WitnessHinduismIslamJainismJudaismSikhismNon religiousSpiritual

*NB if you come on holiday you may want to let us know how we can support your religious practice

Communication Needs

Please let us know if you have any needs that might impact on our communication with you

Hearing needsVisual impairmentEnglish as a second languageSpeech impairmentCognitive difficulties - such as memory problems or difficulties retaining informationN/A

What is the best way for Youth Cancer Trust staff to support your communication needs

Guest Health

Information about your cancer

Cancer diagnosis

Approx date of diagnosis

For our online support please share with us any health conditions that you would like us to know about.

If you decide to come on holiday with us you will be asked to complete a more detailed medical form.

Criminal Convictions

If you tick yes a member of staff will chat to you about it.

I do not have any criminal convictionsI have a criminal conviction

Application Options

Online supportYes - Apply for online support

HolidayYes - Apply for a holiday

Activities and online support

What are you interested in?

Zoom activities

CraftsQuizzes/ Escape rooms/ Murder MysteryOnline parties (themed nights such as Halloween, Harry Potter theme)Baking /Cooking/Eating togetherArtGamingBingoSocial chatsTalks/guest speakers

Facebook live

RelaxationGentle exercise/ yoga

Facebook posts

Connecting with othersReading postsMindfulness /Meditation

Emails

Weekly mail outs for guests

Phone or zoom

Wellbeing 1.2.1 appointments with Wendy and Laura

Holiday Application

Age

I am: Guest (i.e patient) Young Person over 18Guest Young Person under 18

Guest Information

Have you stayed away from home before?YesNo

Medical Information

Information about your cancer

Treatment status:ActiveMaintenanceNon-curativeIn remissionCured

If current status in treatment, maintenance or non curative you must you will need to get your GP or Consultant or CNS to agree that you are well enough to come on holiday and provide us with the information below in case we need to take you to the GP or the hospital.

GP

GP Name:

GP Practice:

GP Telephone Number:

Treating hospital / hospitals:

NHS number:

Consultant Name (if applicable):

Clinical Nurse Specialist (if applicable):

Telephone number for treating team:

Other conditions

Allergies

Carries an epipen for a severe allergy

Another allergy ( i.e food, penicillin, animals, pollen ):

Uses anti histamines

Asthma

Asthmatic and carries an inhaler

Epilepsy/seizures

Carries emergency medication to manage seizures with a clear protocolControlled with medicationOnly prior to diagnosis

Diabetic

Insulin injectionInsulin pumpManaged by diet

Addisons or Adrenal Insufficiency

Carries hydrocortisone injectionOther management

Emergency Protocol

Please state the protocol you follow in an emergency if you have one. (i.e if you had a seizure what do you do/ want us to do). Otherwise we will carry out standard first aid procedures.

Physical Abilities

Note: You need a certain level of independence or happy to receive support from your companion as we are unable to help to with physical care.

Are you able to shower without assistance? YesNo

Are you able to bath? YesNo

Can you manage steps or stairs without assistance? YesNo

Are you bringing your own wheelchair? YesNo

Do you normally use a mobility scooter at home or hire one when you go out? YesNo

Are you able to swim? YesNo

Do you have a PICC line or Hickman line in situ? YesNo

Do you have issues with mobility or dexterity? YesNo

Do you have peripheral neuropathy ( lack or altered sensation often in hands or feet)? YesNo

Do you tire easily walking short distances? YesNo

Please let us know if you have any physical / mobility needs and what you need on your holiday ( i.e you use a wheelchair , get tired easily, unable to do stairs )

Mental Health

Do you consider yourself to have a mental health condition? YesNo

Please let us know how we can support your mental health needs and anything staff can be aware of to help you on your holiday.

Do you have a learning disability? YesNo

Do you have a neurodivergent condition? YesNo

Neurodivergence include autism, Asperger's syndrome, dyslexia, dyscalculia,dyspraxia, ADHD, obsessive-compulsive disorder (OCD), and Tourette syndrome (TS). Please let us know how we can support you.

Fatigue levels and 'brain fog' or memory issues

These are some of the commonest symptoms our guests have to manage.

Do you suffer from fatigue? YesNo

Do you have brain fog? YesNo

Do you have memory issues? YesNo

Please give us more information on your current energy levels and how you best manage.

Medication

Please note you are responsible for your medication. There is a designated medical fridge on site for medication that needs to be kept refrigerated.

Some prescribed medicines contain substances that mean they are called controlled medicines . You will probably know if you are on these and there are some laws around how they are stored. Common examples include morphine, diamorphine, methadone, fentanyl, alfentanil, oxycodone, methylphenidate, dexamphetamine, ketamine and tapentadol.

In order to abide by the law and to ensure safety, staff will need to store these medications in locked cabinet and staff will support you to access your locked medications.

There are other medications /injections such as Epipens or hydrocortisone injections or Midazolam that guests may need to carry on their person.

Please state any specific needs around taking your medication.

Please List Your Current Medicines:

Medication

Dose/When

Administered eg. orally

Over the counter medications will be available for over 18’s to request as long as they complete a medical disclaimer.

Dietary requirements and preferences

Our chef would like to know in advance your dietary needs and preferences.

Allergy to:

Intolerance to:

VegetarianPescetarian (you eat fish but not meat)VeganHalal dietDiabetic/ low sugar dietNo intolerances

Not vegan but drink alternative milk:

I drink:

Oat milk YesNo

Soya milk YesNo

Lactose free milk YesNo

I will not eat:

Other needs you would like us to be aware of (eg. your religious practices (ie. dietary requirements, fasting periods) ):

Dogs

There might be guide/ medical dogs or Laura’s therapy dog present during the holiday.

Please tick if you would like to discuss this as it might be a issue: Yes

UNDER 18's

I agree to (please tick):

My child taking part in the Youth Cancer Trust residential holidayYes

Keeping a record of this form for health and safety reasons in accordance to our GDPR policyYes

Any medical treatment that my child may need to be given in an emergencyYes

That staff will call me if my child requires any over the counter medication such as paracetamolYes

If you are actively under the care of a hospital medical team or have significant health conditions, we do require to discuss with you whether you are well enough to attend a residential stay. Please note that we are not set up to provide medical care to individuals but can respond to emergencies at our local hospital in Dorchester – Dorset County Hospital. We also have a local GP Practice in Puddletown.

It is you’re the applicant or parent/carer responsibility to check with the GP or health professional that you are well enough to attend a holiday. We understand that sometimes situations change and ask that if you can no longer attend your booked holiday, you please inform us asap so we can give the holiday to someone else.

For my child being filmed or photographed during the activity, with the possibility that these photographs/media recordings may be used for publications or marketing publicity. Youth Cancer Trust will take all steps to ensure these images are used solely for the purposes for which they are intended. Note: if consent is not given, Youth Cancer Trust will not use any images taken during the activity that contain the child/young person.Yes

OVER 18's

I agree to (please tick):

For the Youth Cancer Trust to keep a record of this form for health and safety reasons in accordance to our GDPR policyYes

Consent regarding photos and filming with Over 18’s will be asked on arrival.

Companion

Will you be bringing a companion?NoYes

Who’s completing the form:

Young Person completing themselfParent /GuardianOther relativeHealth professional

If not a young person please give name and background info

Guest details and information

Personal Information

Name

Preferred name

Date of Birth

GenderMaleFemaleTransgenderNon-binary/non-conformingPrefer not to respond

Upload a photo

Please upload a photo of yourself so we can recognise you if we need to collect you and so our chef knows who you are if you have any particular dietary requirements.

Contact Details

Street Address

Street Address Line 2

City

County

Postal Code

Country

Contact Number

Email Address

How do you prefer to be contacted

Email (we will need to email you with information)TextWhatsAppPhone call

Emergency Contact

Primary Contact

Name of Emergency contact

Relationship to guest

Mobile number or landline

Secondary Contact

Name of Emergency contact

Relationship to guest

Mobile number or landline

Equal Opportunities

Companion considers their ethnic background to be?

Black CarribeanBlack AfricanBlack OtherWhite caucasianChineseIndianBangladeshiPakistaniPrefer not to respond

Companion's Religion

BuddhismChristianityJehovah WitnessHinduismIslamJainismJudaismSikhismNon religiousSpiritual

*NB if you come on holiday you may want to let us know how we can support your religious practice

Communication Needs

Please let us know if you have any needs that might impact on our communication with you

Hearing needsVisual impairmentEnglish as a second languageSpeech impairmentN/ACognitive difficulties - such as memory problems or difficulties retaining information

What is the best way for Youth Cancer Trust staff to support your communication needs

Criminal Convictions

If you tick yes a member of staff will chat to you about it.

I do not have any criminal convictionsI have a criminal conviction

Age

I am: Companion of Young Person over 18Companion of Young Person under 18

Current age:

Companion Information

Have you stayed away from home before?YesNo

Medical Information

GP

GP Name:

GP Practice:

GP Telephone Number:

Other conditions

Allergies

Carries an epipen for a severe allergy

Another allergy ( i.e food, penicillin, animals, pollen ):

Uses anti histamines

Asthma

Asthmatic and carries an inhaler

Epilepsy/seizures

Carries emergency medication to manage seizures with a clear protocolControlled with medicationOnly prior to diagnosis

Diabetic

Insulin injectionInsulin pumpManaged by diet

Physical Abilities

Please let us know if you have any physical / mobility needs and what you need on your holiday ( i.e you use a wheelchair, get tired easily, unable to do stairs )

Mental Health

Do you consider yourself to have a mental health condition? YesNo

Please let us know how we can support your mental health needs and anything staff can be aware of to help you on your holiday.

Do you have a learning disability? YesNo

Do you have a neurodivergent condition? YesNo

Neurodivergence include autism, Asperger's syndrome, dyslexia, dyscalculia,dyspraxia, ADHD, obsessive-compulsive disorder (OCD), and Tourette syndrome (TS). Please let us know how we can support you.

Fatigue levels and 'brain fog' or memory issues

These are some of the commonest symptoms our guests have to manage.

Do you suffer from fatigue? YesNo

Do you have brain fog? YesNo

Do you have memory issues? YesNo

Please give us more information on your current energy levels and how you best manage.

Medication

Please note you are responsible for your medication. There is a designated medical fridge on site for medication that needs to be kept refrigerated.

In order to abide by the law and to ensure safety, staff will need to store these medications in locked cabinet and staff will support you to access your locked medications.

There are other medications /injections such as Epipens or hydrocortisone injections or Midazolam that guests may need to carry on their person.

Please state any specific needs around taking your medication.

Please List Your Current Medicines:

Medication

Dose/When

Administered eg. orally

Over the counter medications will be available for over 18’s to request as long as they complete a medical disclaimer.

Dietary requirements and preferences

Our chef would like to know in advance your dietary needs and preferences.

Allergy to:

Intolerance to:

VegetarianPescetarian (you eat fish but not meat)VeganHalal dietDiabetic/ low sugar dietN/A

Not vegan but drink alternative milk:

I will not eat:

Other needs you would like us to be aware of (eg. your religious practices (ie. dietary requirements, fasting periods) ):

UNDER 18s

I agree to (please tick):

My child taking part in the Youth Cancer Trust residential holidayYes

Keeping a record of this form for health and safety reasons in accordance to our GDPR policyYes

Any medical treatment that my child may need to be given in an emergencyYes

That staff will call me if my child requires any over the counter medication such as paracetamolYes

for my child being filmed or photographed during the activity, with the possibility that these photographs/media recordings may be used for publications or marketing publicity. Youth Cancer Trust will take all steps to ensure these images are used solely for the purposes for which they are intended. Note: if consent is not given, Youth Cancer Trust will not use any images taken during the activity that contain the child/young person.Yes

OVER 18s

I agree to (please tick):

For the Youth Cancer Trust to keep a record of this form for health and safety reasons in accordance to our GDPR policyYes

Consent regarding photos and filming with Over 18’s will be asked on arrival.

By clicking the 'Submit' button, you are confirming that all the information on this form is correct at the time of application.