Adult Information Submission

Adult Information Form

This form collects information from adults involved with the trip.

Part 1: Adult Information
Name*
First Middle Last
Maiden Name
(if applicable)
Preferred Name
Gender*
Address*
Street Address Address Line 2 City Province Postal Code
Date of Birth*
YYYY slash MM slash DD
Email Address*
Home Telephone*
Cell Phone*
Work Phone
AC Emp # (If Applicable)
Part 2: Flight Attendence
If you answer YES, the rest of the form will populate, please complete all sections. If you answer NO, parts of the form will stay hidden, please answer the sections that appear for you.
Will you be going on the flight?*
What will your role be?*
Part 3: Roles & Responsibilities
Chapter Location
Which chapter location are you in?
Are you with Dreams Take Flight or a sponsor?
Company/Group

If you are a sponsor, please enter the company or group you are with.
Have you gone on the flight in the past?
What is your roll?
Park/Age Preference
This is just a preference. We will do our best to put you in the park with the age group you prefer but it is not guaranteed.
Part 4: Passport
Passport Number
Passport Expiry
DD slash MM slash YYYY
Passport Photocopy Upload
Must be valid 6 months post April 26, 2023
Max. file size: 293 MB.
Part 5: Adult Particulars
Eye Colour
Hair Colour
Height
Scars or Birthmarks
Special Dietary Requirements / Special Meal Needs (Due to allergies, medical or religious reasons)
Medications
Simply hit the "+" icon to add a new item.
Photo
Max. file size: 293 MB.
Please upload a photo (head shot) of yourself.
Part 6: Health Card
Health Card Number
Health Card Province
Health Card Expiry Date
MM slash DD slash YYYY
Part 7: Medical History & Insurance Info
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?
What 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?
Any 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 selected
5) Do you require assistance to sit upright and walk?
Any other info?
6) Do you have problems with bowel or urinary functions?
Any other info?
7) Do you require supplemental oxygen?
Any other info?
8) Do you require a feeding tube?
Any other info?
9) Do you use a wheelchair or other mobility device?
Any other info?
10) Do you use any special devices which you require all the time?
Any other info?
Do you have at least 2 doses of a valid Covid-19 vaccine?
In order to partake in Dreams Take Flight day of flight you must have at least 2 doses of a valid Covid-19 vaccine.
Proof of Vaccine
Max. file size: 293 MB.
Part 8: Emergency Contact Information
Name*
First Last
Relationship*
Home Telephone*
Cell Phone*
Part 9: Adult Clothing
T-Shirt Size
Jacket Size
Part 10: Chaperone Agreement
Please read and check the boxes then initial below to agree to the statements.
Acknowledgements
- I acknowledge that this is a 100% non-smoking day and 100% non-cellphone day)
- I hold a valid Canadian Passport that will not expire within 6 months post flight.
- I have uploaded a copy of my passport to this form.
- As a Dreams Take Flight chaperone, I am a responsible and able to attend to any special needs of the children in my group.
- I agree to stay with my group for the duration of the entire day.
- I am able to endure a very long and strenuous day (approx. 24 hours)
- I acknowledge that alcohol is not permitted during the day of flight.
- I agree to having a RCMP background check.
- I agree to attend an information session prior to flight day (mandatory).
- I agree to follow all Disney park rules including not groups with other Dreams Take Flight groups in lines or on attractions.
Initials
Part 11: Required Declarations
Please read and check the boxes then initial below to agree to the statements.
Declarations*
- I hereby authorize Dreams Take Flight Halifax to conduct a criminal record check/background check in order to determine suitability for Dreams Take Flight endeavors.
- I declare that there is nothing my background or disposition that would make me inappropriate to be involved in Dreams Take Flight endeavors.
- I solemnly promise that after the flight, I will by no means, keep in contact with ANY of the children involved with Dreams Take Flight through any means (social media, telephone, email, letter, etc.) If any volunteers breaks this promise in any fashion, they will be asked to resign from any further involvement/contact with the Dreams Take Flight charity. Having said this, we understand that there are chaperones who work, on a daily basis, with some of these children and already have an existing relationship with those children.
Initials*
Part 12: Acknowledgement/Consent
I acknowledge*
- That all the above information is true to the best of my knowledge.
Applicant Name*
First Last
Applicant Signature*
Witness Name*
First Last
Witness Signature*
Signed on this date
MM slash DD slash YYYY
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

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Adult Information Form

Part 1: Adult Information

Part 2: Flight Attendence

Part 3: Roles & Responsibilities

Part 4: Passport

Part 5: Adult Particulars

Part 6: Health Card

Part 7: Medical History & Insurance Info

Part 8: Emergency Contact Information

Part 9: Adult Clothing

Part 10: Chaperone Agreement

Part 11: Required Declarations

Part 12: Acknowledgement/Consent

Dreams Take Flight | Halifax

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