Elementor #11200 Adult Information Form This form collects information from adults involved with the trip. X/TwitterThis field is for validation purposes and should be left unchanged.Adult InformationLast Name* Last (as listed on your passport)Given Name(s)*(as listed on your passport)Name you go byGender*MaleFemaleOtherLanguages Spoken (fluent) English French Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Date of Birth (YYYY-MM-DD)*Email Address* Home Telephone*Cell Phone*Work PhoneAC Emp # (If Applicable)Adult ClothingDo you have a royal blue flight day polo? Yes No If no, please provide your T-Shirt Size*Men - SmallMen - MediumMen - LargeMen - X LargeMen - 2X LargeMen - 3X LargeWomen - Extra SmallWomen - SmallWomen - MediumWomen - LargeWomen - X LargeWomen - 2X LargeWomen - 3X LargeChapter & Agency InfoChapter Location*Which chapter location are you in?-- Select One --OttawaDate of Flight* MM slash DD slash YYYY Departure Location*-- Select One --Edmonton International AirportToronto International AirportOttawa MacDonald Cartier International AirportPassportPassport Number*Passport Country of Issue*Passport Place of Issue (as listed on passport)*Passport Issue Date (YYYY-MM-DD)*Passport Expiry Date (YYYY-MM-DD)*Place of Birth (as listed on passport) (City, Country)*Passport Photocopy Upload*Must be valid 6 months post Nov 17, 2026Max. file size: 50 MB. Adult ParticularsEye Colour*Hair Colour*Height*Weight (kg)*Scars or BirthmarksSpecial Dietary Requirements / Special Meal Needs (Due to allergies, medical or religious reasons)MedicationsSimply hit the "+" icon to add a new item. Health CareHealth Card ID*Put your Health Card Number here.Health Card Expiry (YYYY-MM)*Health Card Photocopy Upload*Max. file size: 50 MB. Must be valid until at least November 30th, 2026Medical History & Insurance InfoFor all adults participating in the Dreams Take Flight Program: Please provide your medical history below. If you answer "YES" to any of the following, please provide additional medical information in the responding textbox.1) Are you currently taking any prescription medication?*--YesNoWhat kind of medication?2) Have you ever required or received medical treatment, or prescription medications for or had heart / cardiovascular condition or a stroke /cerebral vascular condition or an aneurysm?*--YesNoAny other info?3) In the past 12 months (6 months for high blood pressure) have you:* Received any new prescription medication or new medical treatment for any medical condition? Had any prescription medication changed, reduced stopped or increased for any medical condition? (not including a change between brand name & generic brand) Neither What was this new prescription or medical treatment?Which prescription medication changed?4) In the past 5 years have you required or received medical treatment or taken prescription medication for or had any of the following:* Lung / Respiratory Condition Diabetes (which is controlled by diet, medication, or with insulin) Any test, investigation, or surgery recommended but not yet completed Cancer or Leukemia Blood disorder Kidney disorder requiring dialysis or Liver disorder Circulatory disorder of the arteries or veins Pancreatic disorder Muscle, bone, joint disorder (not arthritis) Stomach or bowel disorder Urinary disorder Parkinson's Disease or seizures High Blood Pressure (Hypertension) Prostate disorder Any other preexisting condition currently requiring medication? None of the above Please provide additional information on the conditions previously selected5) Do you require assistance to sit upright and walk?*--YesNoAny other info?6) Do you have problems with bowel or urinary functions?*--YesNoAny other info?7) Do you require supplemental oxygen?*--YesNoAny other info?8) Do you require a feeding tube?*--YesNoAny other info?9) Do you use a wheelchair or other mobility device?*--YesNoAny other info?10) Do you use any special devices which you require all the time?*--YesNoAny other info?Emergency Contact InformationMust be valid from 4 AM Tuesday - 1 AM Wednesday.Name* First Last Relationship*Home Telephone*Cell Phone*Police Record Check for the Vulnerable SectorEvery volunteer must submit a Police Record check for the vulnerable sector. Please upload a copy of your valid Police record Check for the vulnerable sector (must be less than 2 years old from November 17, 2026).*Max. file size: 50 MB. Information for GroupingHow long have you been involved with Dreams Take flight Ottawa?Have you ever been on flight? If so, how many times?Have you ever been a group lead on our flight?*Do you have any special training/experience that would lend to the cohort of children that we serve?*AcknowledgementAcknowledgements* I acknowledge that this is a 100% non-smoking day and 100% non-cellphone day) I understand that this is a 24 hour day, and that I must be in good health to participate on flight day I recognize that I must complete my Police Record Check for the Vulnerable Sector prior to Orientation Day on October 17, 2026. I have read and understand the Dreams Take Flight Ottawa Code of Conduct I understand that my participation in flight is subject to approval by US Customs and Border Protection and Canada Border Service Agency approvals
