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When you donate to CHSCF your generosity will support young adults managing a cancer diagnosis. Here is how your donations are used:
- $25 supports an Information Bag available online or through a Michigan hospital system.
- $125 sends a travel backpack to a young adult traveling to a survivorship program in the U.S.
- $700 is the average flight cost supporting the CHSCF travel assistance program.
- $1,000 supports a CHSCF Base2Summit scholarship for post-high school learning.
- $2,000 is the average cost per person to attend the CHSCF Base2Summit survivorship program.
Donation Amount*
Your Donation
Email*
Billing Information
Billing Name*
First Last
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Credit Card*

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Welcome to the Base2Summit application! This application is the basics we need to get started on placing you on a B2S week.

If you get stuck at any point, feel free to email base2summit@chscf.org for help or check out our FAQs link on the Base2Summit main webpage.

Once you complete the questions, you’ll hear from someone on our team. We like to connect over the phone so let us know what day of the week and time is best to reach you. (Promise, this won’t be awkward.) If that’s not possible, let us know if email or text is best.

If, after starting this application, you find that you do not have the time to complete it, click the "Save and Continue Later" link at the bottom of this page. This will give you a link you can use to access your partially completed form in the next 30 days. You can also have this link sent to your email address.
General Information:
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
Cell Number*
Email*
Full Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation*
Emergency Person:
Name*
First Last
Cell Number*
Email*
Relationship to Applicant*
T-shirt Size*
Unisex sizes
Best way and/or time to reach you*
Let’s get to know you a bit:
How did you hear about Base2Summit?*
Have you been to other survivorship programs? Tell us where and when.*
Do you have any dietary needs you’d like us to honor?*
Do you have any physical limitations we should be aware of?*
Please make us aware of any emotional needs we could lend support to during B2S.*
Is there anything you’d like us to know upfront that would be helpful in maximizing your experience at B2S?*
Healthcare Providers:
Primary Care:
Name*
First Last
Phone Number*
Email*
Cancer Center:
Name*
*
City State / Province / Region
Oncologist:
Name*
First Last
Phone Number*
Email*
When was your last oncology follow-up?*
Date Format: MM slash DD slash YYYY
Health Insurance:*
upload copy of card
Health History Information:
Primary cancer diagnosis:*
Year of original diagnosis:*
Is there a secondary cancer diagnosis or any medical conditions caused by your primary cancer?*
Without including every detail, give us the basics of your cancer treatment.*
Chemo, Radiation, Surgery, with most recent dates included
Are you currently in treatment of any kind? Tell us about it.*
Are you allergic to anything? (Environmental, food and/or medications) If yes, please list here.*
Have you had any non-cancer related injuries or conditions that would affect your ability to participate in outdoor adventure activities?*
Are your immunizations up to date (including tetanus)?*
Have you had COVID-19 or been vaccinated for it?*
Upload your vaccination or immunization records here.*
Why not?*
Are you diabetic? If yes, how is it treated?*
Have you had seizures? If yes, type and frequency.*
Have you ever fainted? If yes, frequency and cause, if known.*
Do you have frequent headaches that affect your daily routines? If yes, how often?*
Do you have asthma or shortness of breath? If yes, how is it treated?*
Base2Summit will likely include (but not limited to) biking, hiking and water sports (ie:kayaking SUP, swimming, boating, sailing). Do you have any fears, limitations or concerns we should be aware of?
Medications
List all current mediations (both prescription and non prescription):
Create a list below or upload a typed list.
Upload List of Medications
Authorizations:
Link to Base2Summit policy on tobacco, alcohol and cannabis
Base2Summit policy on tobacco, alcohol and cannabis*
I consent to the Base2Summit policy on tobacco, alcohol and cannabis.
Link to participant release agreement
Participant release agreement*
I consent to the participant release agreement.
Copy of medical advance directive
if applicable
Phone
This field is for validation purposes and should be left unchanged.

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Billing Information

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General Information:

Emergency Person:

Let’s get to know you a bit:

Healthcare Providers:

Primary Care:

Cancer Center:

Oncologist:

Health History Information:

Medications

Authorizations: