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2018 Holiday Application
Holiday Weekend Application December 14-16, 2018
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* Indicates required question
Email
*
Your email
Dream Day Family Information
**Please note that Dream Day serves immediate family members only**
Child's Name
*
Your answer
Gender Identity
*
Male
Female
Address
*
Include City, State, and Zip code
Your answer
Diagnosis
*
Your answer
Date of Diagnosis
*
MM
/
DD
/
YYYY
In Remission?
*
Yes
No
N/A
If Yes, Since When?
Your answer
Age
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Current Grade In School
*
Your answer
Child's Primary Language
*
Your answer
Can He/She Speak English?
*
Yes
No
Would Your Family Need A Wheelchair Accessible Room?
*
Yes
No
Parent/Guardian Names
*
Your answer
Home Phone
*
Your answer
Work Phone
*
Your answer
Cell Phone
*
Your answer
Please list youth siblings (under 18) planning to attend
*
Include Full Name, Age, M/F
Your answer
Please tell us any other information we may need to know about your family
This may include any questions or concerns you have
Your answer
General Information
How did you hear about Dream Day on Cape Cod?
*
***Hospital
Internet
From other attendees
Other:
**If Hospital please list the Name, Position, and Hospital of the Medical Personnel
Your answer
Have you ever been to Dream Day's Holiday Weekend before?
*
Yes
No
If yes, please list when
Your answer
Have you attended our Summer Program?
*
Yes
No
If yes, please list when
Your answer
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