First Name

Last Name

Phone Number

Email Address

Street

City

Province

Postal Code

What is the name of your dialysis centre?

What is the name of your kidney doctor?

How long have you been on dialysis?

Have you been to Camp Dorset before? Have you been to Camp Dorset before? Yes No

What are your support requirements? What are your support requirements? Transportation Camp Fees Food Bringing Family or Friend Other

Please briefly tell us why you think you should be chosen to be sponsored by Kidney CARE Network International to go to Camp Dorset? Please do not exceed 500 words.