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Adult Info Forms – Day of Flight

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

Adult Information

Name*

First Last

Name you go by

Gender*

Address*

Street Address Address Line 2 City Province Postal Code

Date of Birth*

YYYY slash MM slash DD

Email Address*

Please ensure the email is accessible 7 days a week unlike some work emails which may not be.

Home Telephone*

Cell Phone*

Work Phone

AC Emp # (If Applicable)

Chapter Info

Chapter Location*

Which chapter location are you in?

Date of Flight*

MM slash DD slash YYYY

Departure Location*

What's your role?*

Passport

Passport Number*

Passport Expiry*

DD slash MM slash YYYY

Passport Photocopy Upload*

Must be valid 6 months post Sept 22, 2026

Max. file size: 50 MB.

Adult Particulars

Eye Colour*

Hair Colour*

Height*

Weight (kg)*

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.

Organization/Group

This section is not for Dreams Volunteers

Organization/Group Name

Health Care

Health Care ID*

Put your Alberta Health Care Number here.

Medical Declaration form (from email)*

Must be stable for previous 90 days or own travel insurance will be required.

Max. file size: 50 MB.

Medical History & Insurance Info

For guardians or chaperones participating in the Dreams Take Flight (DTF) 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?*

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?

Emergency Contact Information

Must be valid from 4 AM Wednesday - 1 AM Thursday.

Name*

First Last

Relationship*

Home Telephone*

Cell Phone*

Adult Clothing

Do you have a wearable red Dreams Take Flight shirt from previous flights?*

If your answer is no, please select a size from below options.

T-Shirt Size (Unisex)

Acknowledgement

Acknowledgements*

I acknowledge that this is a 100% non-smoking/vaping day and 100% non-cellphone day

I have completed my CRC / VSC checks OR submitted the request to the proper authority

https://yeg.dreamstakeflight.ca/wp-content/uploads/sites/6/2023/08/2023-Adult-Med-Declaration.pdf

Before You Submit!

Please download this declaration form to submit to us later:

Adult Medical Declaration

Dreams Take Flight | Edmonton

Dreams Take Flight stretches children’s minds. As poet Oliver Wendell Holmes wrote, “One’s mind, once stretched by a new idea, never regains its original dimensions.”

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