Oncology Camp Application

Thank you for registering for Camp Heart Connection! All applications must be returned no later than May 1, 2013, for Oncology Campers. Camp Heart Connection's Oncology Camp dates are June 9-15. Please note: All required questions must be answered to process your application. Also, as space is sometimes limited at Camp Heart Connection, applications will be processed on a first come, first served basis. Please continue to complete the form below:
To be completed by parent/guardian:
Campers First Name	*
Campers Middle Name	*
Campers Last Name	*
Social Security Number	*
Birth Month	*
Birth Day	*
Birth Year	*
Age at Camp	*
What grade was the camper in for the 2012-2013 school year?	*
Sex	*	Male Female
T-shirt Size:	*
Name as you would like it to appear on name tag:	*
Camper Email
Can we share this email address with other Camp Heart Connection participants?		Yes No

Parent or Guardian Information:
First Name	*
Last Name	*
Home Phone Number (ex. 1234567890)
Work Phone Number (ex. 1234567890)
Cell Phone Number (ex. 1234567890)
E-mail Address
Address	*
City	*
State	*
Zip / Postal	*

Second Parent/Guardian Information:
First Name
Last Name
Home Phone Number (ex. 1234567890)
Work Phone Number (ex. 1234567890)
Cell Phone Number (ex. 1234567890)
E-mail Address
Address
City
State
Zip / Postal

Do both parents have custody of the camper?	*	Yes No
If no, please explain:

Person to be contacted in case of an emergency (other than parent) if parent(s)/guardian(s) cannot be reached:
First Name	*
Last Name	*
Relationship to Camper	*
Home Phone (ex. 1234567890)
Work Phone (ex. 1234567890)
Cell Phone (ex. 1234567890)

Medical History:
Type of cancer
Cancer diagnosis/date of onset (mm/dd/yy)
Is your child currently on treatment?	*	Yes No
If no, month and year of last treatment:
Central Line: Does your child have a central line?	*	Yes No
Is he/she able to care for this?		Yes No
Ostomy: Does your child have an ostomy?	*	Yes No
Is he/she able to care for this?		Yes No
Port: Does your child have an infusaport or portacath?	*	Yes No
Is he/she able to care for this?		Yes No
Will it need to be flushed the week of camp?		Yes No
Treatment Facilities: Please check all of the treatment facilities your child was/is treated at:		University of Iowa Children's Hospital Blank Children's Hospital Omaha Mayo St Jude's Other
Chronic or reoccuring illness or medical condition:
Other Diseases:

For Female: Has this person menstruated?		Yes No
If not, has she been told about it?		Yes No
If so, is her menstral history normal?		Yes No
If no, please explain:
Name of family physician:	*
Phone number of family physician (ex. 1234567890)	*

Insurance Information:
Do you carry medical/hospital insurance?	*	Yes No
If so, indicate carrier:
Name of Person with Insurance (first and last):
Policy or Group Number:
Carrier Street Address:
Carrier City:
Carrier Zip Code:
Carrier State:
Please submit a copy of your insurance card one of four ways:
1.) Upload below (preferred method)
Please upload a copy of your insurance card:
2.) Email to Channon@ChildrensCancerConnection.org
3.) Fax to 515-243-5232
4.) Mail to Children's Cancer Connection, 1221 Center Street, Suite 12, Des Moines, IA 50309

Camper Health History:
Health History: Check if YES		Frequent Ear Infections Heart Defect/Disease Convulsions/Seizures Diabetes Bleeding/Clotting Disorders High Blood Pressure Mononucleosis Asthma
Diseases: Check if YES		Mumps German Measles Measles Chicken Pox
Drug Allergies: Does your child have any drug allergies?	*	Yes No
If so, please check which drugs.		Penicillin Sulfa drugs Tetracycline Codeine Non-steroidal anti-inflammatory drugs (NSAIDs) Phenytoin Carbamazepine
Please list any other known drug allergies
Food Allergies: Does your child have any food allergies?	*	Yes No
If so, please check those foods.		Peanuts Soy Tree Nuts Milk Shell Fish Eggs
List any additional food allergies
Please list any additional dietary restrictions:
Seasonal Allergies: Does your child have hay fever or seasonal allergies?	*	Yes No
Significant Medical/Surgical History:
Please list any surgeries or other medical history (along with dates) that you feel is important in the care of your camper -
Special Medical Needs: Please list any other special medical attention that your child may require.

Medication During Camp: Medications are dispensed at each meal and at bedtime. We would prefer to give as many evening medications as possible with dinner. If the evening medications must be given at bedtime, please indicate below.
Name of Medication
Route (Mouth, IV, SQ, ect.)
Dosages
Time of day to be given		Breakfast Lunch Dinner Bedtime
Frequency (include even and odd days)

Name of Medication
Route (Mouth, IV, SQ, ect.)
Dosages
Frequency (include even and odd days)
Time of day to be given		Breakfast Lunch Dinner Bedtime

Name of Medication
Route (Mouth, IV, SQ, ect.)
Dosages
Frequency (include even and odd days)
Time of day to be given		Breakfast Lunch Dinner Bedtime

Name of Medication
Route (Mouth, IV, SQ, ect.)
Dosages
Frequency (include even and odd days)
Time of day to be given		Breakfast Lunch Dinner Bedtime

Name of Medication
Route (Mouth, IV, SQ, ect.)
Dosages
Frequency (include even and odd days)
Time of day to be given		Breakfast Lunch Dinner Bedtime

Name of Medication
Route (Mouth, IV, SQ, ect.)
Dosages
Frequency (include even and odd days)
Time of day to be given		Breakfast Lunch Dinner Bedtime

Name of Medication
Route (Mouth, IV, SQ, ect.)
Dosages
Frequency (include even and odd days)
Time of day to be given		Breakfast Lunch Dinner Bedtime

Name of Medication
Route (Mouth, IV, SQ, ect.)
Dosages
Frequency (include even and odd days)
Time of day to be given		Breakfast Lunch Dinner Bedtime

Name of Medication
Route (Mouth, IV, SQ, ect.)
Dosages
Frequency (include even and odd days)
Time of day to be given		Breakfast Lunch Dinner Bedtime

Name of Medication
Route (Mouth, IV, SQ, ect.)
Dosages
Frequency (include even and odd days)
Time of day to be given		Breakfast Lunch Dinner Bedtime

More information about health procedures will be sent prior to camp.



Children's Cancer Connection has always made camp possible to children and families at no charge. So we can continue doing this, we are asking for your help by providing our fundraising committee with leads for financial support in your community. Please take a moment to complete this section.
Financial Support Ideas:
Parent/Guardian First and Last Name:
Employer
Employer's Address
Does your company have a charitable gift program?
If so, may we direct a request for funding to your company and to whom should we send it?


Coins for Campers consists of a week-long change drive. Students collect pennies, nickels, dimes, quarters, and any other monetary donations throughout the week and are able to use their creativity in how this is done. At the end of the change drive, the class or homeroom that collects the most money will receive a free pizza party, and a gift card to an office supply store will be rewarded to the winning class’ teacher.
School child attends
School Address (#, street, city, state, zip)
Whom should we send an information packet to?
First and last name
Title

Please list any other companies, schools or service clubs in your area that are known to be charitable:
Company, school or club name
Contact name and address
Company, school or club name
Contact name and address

Camper Consent Information: The following consents are for (Applicant's Legal Name)...
First Name	*
Middle Name (Not Abbreviated)	*
Last Name	*
Permanent Address (Number, Street, City, State, Zip):	*

To be completed by all applicants. Form must be signed by parent/guardian if under 18.
Authorization for Treatment:
I, for and on behalf of the applicant named above, hereby give permission to the medical staff of Children's Cancer Connection, selected by the camp director, to order X-rays, routine tests and treatments; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event of an emergency, I hereby give permission for my child to be treated by the physician selected by the camp director or camp medical personnel to secure and administer treatment, including hospitalization, for the person named above. I understand that I am responsible for any and all medical treatment costs that may be incurred by my child while attending Camp Heart Connection offered by Children's Cancer Connection. This completed form may be photocopied for trips outside of camp.
Camper's Acceptance:	*	Yes, I agree to the terms of the Authorization for Treatment statement above.
Date:	*
Parent/Guardian Acceptance (if under 18):	*	Yes, I agree to the terms of the Authorization for Treatment statement above.
Date:	*

Camp Attendance Consent Form & Media Consent:
In consideration of Children's Cancer Connection granting permission for my child to attend and participate in Camp Heart Connection, I the undersigned, for themselves, their legal representatives, successors, and assignees, hereby waive and release any and all rights, claims, demands, and actions whatsoever for damages or loss which the undersigned may have against Children's Cancer Connection . I also grant permission for my child to be transported by a licensed company, to any and all camp activities held off camp premises. I do hereby authorize the interviewing, taking of pictures, motion pictures/video, and/or television pictures of my child, while participating at Children's Cancer Connection's camp, and consent to the use of any or all such pictures in publication media, as well as for use on Children's Cancer Connection's web site, except as noted. (This includes pre-camp press releases announcing participation in the summer camps, as well as my own/my child’s name, address, phone number, and e-mail printed in the annual camp yearbook for distribution amongst camp participants and volunteers.)
Explanation:
Camper's Acceptance:	*	Yes, I agree to the terms of the Camp Attendance and Media Consent statement above.
Date:	*
Parent/Guardian Acceptance (if under 18):	*	Yes, I agree to the terms of the Camp Attendance and Media Consent statement above.
Date:	*

Camper Questionnaire: To be completed with the help of parent or guardian
Dear Camper: In order to help you have a great time at camp, we would like to get to know you better. Please complete the following questions. Please tell us some important things about yourself that we can share with your counselors. (We will only share this information with our staff members.)
Information on this page and the previous page will only be shared with staff selected to work with your child at camp.

Please submit a photo of your child one of three ways:
1.) Upload below (preferred method)
Please upload a photo of your child
2.) Email to Channon@ChildrensCancerConnection.org
3.) Mail to Children's Cancer Connection, 1221 Center Street, Suite 12, Des Moines, IA 50309
**Please do not fax photos.

What is your favorite TV show or movie?	*
What is your favorite food or candy?	*
What is your favorite book/story?	*
Have you been to Camp Heart Connection before?	*	Yes No
If yes, how many years?
Have you been to other overnight camps?	*	Yes No
If you have, which ones?
What do you enjoy most about camp?
Tell us something special that happened to you within the last year	*
What are you looking forward to doing at camp? If there is anything that you would especially like to do or learn at camp, please list it, and we will try to provide that experience for you.
	*
What is your biggest concern about camp this year?	*
Names and ages of other brothers and sisters

Parent/Guardian Questionnaire: Please help our staff get to know your child better.
Is this his/her first time sleeping away from home?
	*	Yes No
Does your child have any special concerns about attending camp or being away from home?
	*	Yes No
Is he/she anxious/uptight around new faces/other children?
	*	Yes No
Does your child require any special assistance? (Including walking aids, prosthetic devices, wheelchair transfers or other specialty equipment needed to make camp a successful experience.)
	*	Yes No
Does your child have trouble controlling bladder or bowel movements?
	*	Yes No
Does your child need assistance with personal hygiene?
	*	Yes No
Does your child have any behavioral problems?
	*	Yes No
Does he/she have any serious fears?
	*	Yes No
Does your child have a history of difficulty sleeping (nightmares, sleepwalking or talking, or bed wetting)? Please explain in the space provided below.
	*	Yes No
Has he/she experienced a death in the family or of a friend in the last twelve months?
	*	Yes No
Does he/she have a particular concern related to their diagnosis, treatment, and/or change in appearance? Or in the case of siblings, do they have concerns?
	*	Yes No
If you have answered yes to any of the above questions, please explain:

If you have answered yes to any of the above, how do you cope with that at home?

Is there anything you feel we should know about your child which will help make their week better?

Rate your child's swimming ability:	*
When swimming, does he/she need:	*
Normal camp activities may include some or all of the following activities: horseback riding, canoeing, zipline, rappelling/climbing wall, riflery, archery, and swimming. All activities are led by certified instructors and campers are carefully supervised. Are there any specific activities you choose not to allow your child to participate in? Please list them here:

Please list any limitations, restrictions, and/or problems at home that the camp staff should know about your child to make the week better and more safe.

Security Code	*