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ADVENTURE FORM
Adventure Form
admin
2019-02-20T23:58:22-08:00
Tell us a little about yourself so we can help get your adventure started.
Please enable JavaScript in your browser to complete this form.
Name:
*
Birthday:
Cancerversary:
Email
*
Phone:
Physical Address: (Street Address)
Physical Address: (City, State Zip)
Family members with ages and shirt sizes:
Physical limitations/physical concerns:
Please rate the following statements below.
(1=Strongly disagree, 2=Somewhat disagree, 3=Neither agree nor disagree, 4=Somewhat agree, 5=Strongly agree)
1. I experience residual fear (ptsd) from my initial diagnosis and treatments:
1
2
3
4
5
2. Fear of recurrence affects my decisions weekly:
1
2
3
4
5
3. Fear of recurrence affects my decisions monthly:
1
2
3
4
5
4. Fear impacts my life on a daily basis:
1
2
3
4
5
5. My cancer experience has negatively affected my children (ages 4-18):
1
2
3
4
5
6. My cancer experience has had a negative impact on my relationship with my children:
1
2
3
4
5
7. My cancer experience has positively affected my relationship with my children:
1
2
3
4
5
8. My cancer experience has had a negative impact on my relationship with my spouse/partner:
1
2
3
4
5
9. My cancer experience has positively affected my relationship with my spouse/partner:
1
2
3
4
5
10. Cancer impacts my ability to live a happy life:
1
2
3
4
5
11. I would describe myself as affected by depression:
1
2
3
4
5
12. I have someone in my life who understands what it is like to live with a cancer diagnosis:
1
2
3
4
5
Describe how your family envisions their adventure day. (All adventures ideally occur within a 3 hour drive of your home.):
(Optional) If your family has a second adventure idea describe it here:
Any additional relevant information can be included here:
Website
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