The Colon Club
2019 On the Rise Featured Survivor/Caregiver App.
Knowledge is power and The Colon Club is changing the perception of colorectal cancer. If you are selected, you will get to attend our advocacy retreat/photo shoot that we lovingly call Colon Camp. Your story will be featured in The Colon Club’s 2019 annual colorectal cancer awareness magazine, baring your scars and sharing your journey.
As a featured survivor/caregiver, you will have the opportunity to connect with others, find your voice to become a strong advocate for colorectal cancer (CRC), and help raise awareness about The Colon Club and our many resources and projects. You will become the voice of young CRC survivors. Participating in local CRC events will be an important part of your role as a survivor/caregiver appearing in On The Rise.
Fundraising for The Colon Club is a way to help us to continue with our mission to educate as many people as possible, as early as possible, about the risk factors and symptoms of colorectal cancer, and for people to get screened when it's appropriate for them. It is also a GREAT way for you to pay it forward so that other CRC survivors/caregivers can have the opportunity to attend Colon Camp.
Complete the following application to be considered for the 2019 issue of On The Rise. The dates of Colon Camp will be June 20 - 24, 2018. You must be available for the entire time of the shoot (no late arrivals or early departures). If you are selected, the following expenses are paid: flight, lodging and all meals while you are at Colon Camp.
Please follow the directions carefully and be sure to attach the correct files to the correct questions below or your application may be delayed being reviewed for selection.
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Democratic Republic of the Congo
Republic of the Congo
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
United States Minor Outlying Islands
Virgin Islands, British
Virgin Islands, U.S.
Phone Number (cell)
Phone Number (home)
You must be available for the entire time of the shoot (no late arrivals or early departures.) The retreat will be June 20 -24, 2018.
CANCER HISTORY (if you are the caregiver, answer these questions about the person you were/are the caregiver for)
Age at diagnosis:
Are you (they) currently cancer free?
Stage at Diagnosis (please use Roman Numerals. ex: Stage I, Stage II, Stage III, Stage IV):
Did you (they)/do you (they) have a temporary or permanent ostomy?
Have you/they ever had genetic testing?
If yes, what did it show? (Ex. Lynch Syndrome)
On the Rise Magazine
Fundraising in order to "pay it forward" so other survivors/caregivers can attend Colon Camp the following year is appreciated, just like those from previous years have done for you. Are you willing to fundraise?
If no, what prohibits you from fundraising?
Do you feel comfortable doing any of the following (check all that apply)?
Participating in CRC Advocacy
All of the above
Have you previously applied to be featured in our annual publication?
If previously applied, please list what year(s):
You have told us about your colorectal cancer or that of the person you are a caregiver for, now we want to know more about YOU as a person. Tell us your story in 1 - 3 pages. **Files MUST be in PDF format.**
Attach a picture of yourself. Please make sure the picture is clear and in Jpeg format:
Picture does not have to be a professional picture. Can be a head or full body shot.
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