Camp Koru Application
Contact Information
First Name
MI
Last Name
Birthdate
Preferred Name
Gender
Please select...
Female
Male
F2M Transgender
M2F Transgender
Nonbinary
Not Sure
Other
Pronoun Preference:
Please select...
She/Her
He/Him
They/Their
Other
I prefer to be roomed with:
Please select...
Female Identifying Participants
Male Identifying Participants
Please Contact Me About Rooming Options
Surf: Participants are housed with 3-4 roommates in cabins. Snow: Participants are housed with 2-3 roommates in bedrooms.
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If Other:
Which category best describes your ethnicity
Hispanic or Latino
Not Hispanic or Latino
Declined
Check all that apply.
Which category best describes your race? (choose all that apply)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Some other race
Declined
T-Shirt Size
Please select...
Women's XS
Women's S
Women's M
Women's L
Women's XL
Men's XS
Men's S
Men's M
Men's L
Men's XL
Men's XXL
Email
Cell
International Phone
Occupation
Mailing Information
Address Line 1
If you live in Canada (especially Alberta or Quebec), this form may not be able to accept the address. Please use our address: 216 Cascade Ave., Hood River, OR 97031, and include your real address at the bottom of the application.
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Address Line 2
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
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Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Provinces
Please select...
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Country
Please select...
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos ( Keeling ) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Côte d ' Ivoire
Croatia ( Hrvatska )
Cuba
Cyprus
Czech Republic
Congo ( DRC )
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands ( Islas Malvinas )
Faroe Islands
Fiji Islands
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia, Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé and Prìncipe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Viet Nam
Virgin Islands ( British )
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Emergency Contact Information
First Name
Last Name
Relationship
Phone
Email
The emergency contact has the same address as the applicant
Please tell us about your cancer and medical history
Diagnosis
How old were you when you were diagnosed?
Any other health issues?
Treating Oncologist
First Name
Last Name
Phone
Email
Cancer Center/Institute
Where does your oncologist practice? Example: OHSU, MD Anderson, Dana Farber, etc.
x
Are you still followed by this oncologist?
Yes
No
Current Physician (PCP) or Oncologist
First Name
Last Name
Phone
Email
Cancer Center/Institute
Which Camp do you want to attend?
We have a waitlist for our camps and are doing our best to get you to one of our in-person camps as soon as we can! We are hoping to add more opportunities for applicants to attend in 2021, so please check out our website for up to date information! If you have questions, please email: programs@projectkoru.org.
What is your swim level?
Please select...
Doggy Paddle
Intermediate
Strong
Competitive
Can't Swim
Surf/Paddling Experience
Please select...
None
Beginner (not catching waves consistently)
Intermediate (can paddle into and often catch waves)
Advanced (can paddle into chest & high waves consistently)
We expect most to select "None" here, but if you have prior experience, please let us know.
x
Skiing Experience
Please select...
None
Beginner (can go down green run)
Intermediate (can go down blue run)
Advanced (can go down all greens, blues, & most black runs)
We expect most to select "None" here, but if you have prior experience, please let us know.
x
Snowboarding Experience
Please select...
None
Beginner (can go down green run)
Intermediate (can go down blue run)
Advanced (can go down all greens, blues, & most black runs)
We expect most to select "None" here, but if you have prior experience, please let us know.
x
What other sports have you participated in?
Mountain biking, yoga, kayaking, hiking, running, etc., or none
x
Do you have any physical restrictions and/or any special needs?
Help us get to know you!
How did you hear about this program?
Describe your experience with cancer
Share as much or as little as you would like, from detailed info about your diagnosis, to how cancer has affected your life.
x
What is your survivorship birthdate & what it's significance for you?
This could be your last day of treatment, first day of remission, a surgery date, or whatever you consider that special day you'll never forget that signifies moving forward after cancer.
x
How do you feel you would benefit from attending Camp Koru?
Basically, tell us why you want to go!
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Please tell us any topics you'd like to discuss at camp
Please share your dietary restrictions.
(We cook very healthy, mostly organic ingredients for our camp.)
please be as specific as possible. example: "gluten free, but things like soy sauce are okay" or "severe peanut allergy", etc.
x
Historical Camp Experience
Have you ever attended a camp or retreat for cancer survivors before?
Please select...
Yes
No
Have you or do you intend to apply/attend another young adult survivorship program prior to attending Camp Koru?
Please select...
Yes -- I have been accepted to another young adult survivorship program
Yes -- I have applied or plan to apply to other young adult survivorship programming
No -- I have not, and do not anticipate attending another survivorship program prior to attending Camp Koru
Was this camp dedicated to young adult survivors?
Please select...
Yes
No
Please tell us which young adult survivorship camp(s) you've attended
First Descents
True North Treks
Survive & Thrive
Send It
Camp Mak-A-Dream
Other
Which First Descents Program(s) did you attend?
Please be specific:
1. Location, 2. Activity, 3. Month/Year, 4. Weekend or Week-long
Please tell us when you went, 1. which FD program(s) you did (FDi, FD1, FDX), 2. what activity you participated in (surfing, kayaking, rock climbing, etc.), 3. Location (Hood River, Moab, North Carolina, etc.), and 4. Date (ideally, month and year)
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When did you attend True North Treks? Was this camp a week long or over the weekend?
Which Survive & Thrive Program(s) did you attend? Was this camp a week long or over the weekend?
Please tell us when you attended Survive & Thrive, and which program you attended (Grand Canyon, Owyhee River, Sailing, etc)
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Which Send-It Program(s) did you attend? Was this camp a week long or over the weekend?
Please tell us when you attended a Send-It program and which activities you participated in (surfing, skiing/snowboarding, etc)
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Which Camp Mak-A-Dream did you attend? Was this camp a week long or over the weekend?
Please tell us which Camp Mak-A-Dream you attended (Heads Up Conference, Young Adult Camp, etc), and when.
x
What other camp did you attend for young adults with cancer? Was this camp a week long or over the weekend?
Please share any other camp or retreat you attended specifically for young adults with cancer.
x
Please list any other camps/retreats for survivors you have attended Was this camp a week long or over the weekend?
Please tell us what, specifically, you hope to get out of attending another camp/retreat for young adult cancer survivors.
Please be as specific as possible. Now that you've been to one camp/retreat, do you hope to get anything new out of the Camp Koru experience?
x
Please feel free to provide any additional information that you think would be helpful for us.
Today's Date
Contact Information