Application Form | Youth Cancer Trust

    Youth Cancer Trust application form for holidays and online support.

    If you are eligible for a Youth Cancer Trust Holiday, please complete and submit the following full application form. If you are unsure, please complete the enquiry form or contact us on 01202 763591. Once we have received your submitted form, we will be in touch to arrange the details of your holiday.

    Sign up to Realshare Online Support – Please also complete and submit this form to join our Realshare community – our FREE online support and activity programme. Once we have received your form, we will be in touch with your login details and to talk to you about all the activities on offer and how to take part.

    We NEVER share your details with anyone - anything you share with us is private and confidential.


    Applicant Details


    Contact Details


    Equal Opportunities


    Medical Information

    Name of GP:

    Name of Consultant or Cancer Nurse Specialist:

    Has the applicants' treatment finished?

    If you answered yes to the last question, when did the treatment finish?


    Current On-going Medical Status

    PLEASE NOTE - To meet the criteria for a Youth Cancer Trust holiday, the applicant will need to be able to self medicate.

    Please List Your Current Medicines:


    Allergies:


    Current Medical Issues:

    In this section, please describe how your current diagnosis and treatment affects you. Also include any other health issues we need to be aware of.


    Current On-going Needs:


    Daily Living:

    Please complete this section to let us know about anything else that may impact on your ability to participate in activities and how we can support you.


    Mental Health:

    Please add Details / Suggestions / Information?


    Covid 19

    [radio* covid use_label_element "Yes" "No" "Medically exempt"]

    Emergency Contact

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


    Criminal Convictions


    Application Options

    Holiday Application


    Holiday Dates

    Please note - Youth Cancer Trust holidays take place from Mondays to Fridays (not weekends), all year round.

    First Choice of Holiday Date - Our holidays run from Mondays to Fridays (not weekends). Please choose any Monday as your preferred holiday date.

    In case your first choice is already fully booked, please enter your second choice of holiday date - Our holidays run from Mondays to Fridays (not weekends). Please enter any Monday as your preferred holiday date.


    Companion

    Companion's Name

    Companion's Address

    Companion's Parent / Guardian:

    Companion's Daily Living:

    Please add Details / Suggestions / Information

    Covid 19

    [radio* companion-covid-choice use_label_element "Yes" "No" "Medically exempt"]

    Your Parent / Guardian / Next of Kin details in case of an emergency

    Full name of Parent / Guardian / Next of Kin:

    Parent / Guardian / Next of Kin Phone Number:


    Please confirm your GP or Consultant has agreed you are fit to come on a Youth Cancer Trust holiday.


    Emergency Medical Treatment Consent

    In the event of a need for emergency medical treatment and parents/guardians/next of kin cannot be contacted. I (parent/guardian/next of kin) give permission to the staff of Youth Cancer Trust Holidays to give consent for such treatment for the applicant on my behalf:


    Youth Cancer Trust Holiday Activities

    Activities are optional and if the applicant does not feel well enough to take part, they can either accompany the group or stay at the house. Activities can include horse riding, go karting, water sports, sailing amongst others


    Transport Planning

    Please read and complete the following carefully: Please book your travel tickets at least 14 days in advance to obtain preferential rates and then confirm all of your travel arrangements with the office (01202 763591 or admin@yct.org.uk or via our Facebook page). If you need help with your travel arrangements, please let us know as soon as possible at the time of booking your holiday. YCT holiday guests and companions are asked to arrive after 2pm on the Monday and to leave Tracy Ann House by 11am on the Friday if possible. We understand if train times do not permit this.


    Parent / Guardian Consent - If Applicant Is Under 18

    If applicant is under 18. “To the best of my knowledge, at this time, this is a true and accurate description of my child’s needs”


    Agreement

    We understand that sometimes holidays have to be cancelled at short notice due to ill health. However, if you have to cancel due to work or other activities, please do give us as much notice as possible. These holidays cost the charity substantial amounts of money so please allow us plenty of time to offer your place to someone else.

    Person completing form


    Publicity

    To encourage funding and support of the Youth Cancer Trust we sometimes use photos of the groups during their holidays and make reference to the applicant's stay at Youth Cancer Trust for press releases and other promotional / publicity materials. We may include their first name (not surname), age and the area they live (not address) E.g. Vicky, aged 16 from Dorset.


    Online Support Application

    If applicant is being referred by a health care service, please provide details:

    Youth Cancer Trust run a secure Facebook group for our guests. If you would like to be added to the Facebook group, please add your Facebook profile or Facebook email address below

    If you are under 18, please ask your parent / guardian to sign to give their permission for you to access our Facebook group.


    Activities and Support

    What activities and support are you interested in?


    Terms and Conditions

    Unless specifically stated, the online activity and support programme, and secure Facebook group is for Youth Cancer Trust guests only.

    The term 'guest' refers to anyone meeting our criteria:

    'young people aged 14 to 30 living with cancer or any malignant disease from anywhere in the UK and Irish Republic or who are patients of any UK hospital. You can also join our program if you have been in remission for up to 5 years, or are living with the late effects of having had cancer as a teenager.'

    At our discretion, we are also currently accepting applicants meeting the above criteria who are over 30 years of age.

    All guests participating in our online programme agree to at all times treat peers and staff respectfully and courteously, or may be asked to leave the programme.

    All content in the secure group including guest’s comments, photos, zoom recordings and zoom links are strictly to remain within the group only and not to be shared publicly, unless permission has been granted from the individual or group moderators.

    Youth Cancer Trust will not tolerate any bullying or intimidating behaviour and reserve the right to remove and block anyone from accessing the secure group and activities if they do not adhere to the above conditions.

    Should guests experience any bullying from peers or they have any concerns / grievances please report to one of the group moderators immediately.

    Guests participating in physical activities hosted by Youth Cancer Trust must seek advice / permission from their GP first if they are not currently physically active.

    Agreement


    Other


    Thank you for taking the time to complete this form

    The completion of this form is a legal requirement for Youth Cancer Trust. Please Note Youth Cancer Trust does not disclose personal data to third parties. Personal data is kept confidential and only used for the purposes of arranging your holiday and keeping in touch with you. If you have any questions relating to this form or Youth Cancer Trust holidays please telephone 01202 763591 and we will be happy to help.

    By submitting this form, you are adhering to our terms and conditions and if you are under 18 you are confirming that you have permission from a parent or guardian that you are allowed to join the online community. Your details will be kept safe in line with our strict data protection policy.