Purchase a Car Raffle Ticket
Here!
Please click
here
for updates regarding 2021 Summer Programming
Menu
Our Camp
What We Do
History
Staff/Board of Directors
Financial
Offices
Employment
Our Programs
Child Oncology Programs
Adult Oncology Programs
Community Programs
Events
Regions
Western NY
Central NY
Rochester, NY
Media
Press Contacts
In the News
Digital Assets
Photo Gallery
Founder's Blog
Radio Show
Ways to Give
Good Days Givers (Monthly Giving)
Raffles
Fundraisers
Virtual Kazoo Fest
Cookbook
Face Masks
External Fundraisers
Ugly Sweater Contest
Planned Giving
Corporate Engagement
Donate Now
Donate Today
Become a Volunteer
Sign Up
Please choose one: Camp Good Days offers programs for:
Children With Cancer (under the age of 18)
Women with cancer (18+)
Children (under the age of 18) who have, or have lost, a parent or sibiling with cancer
Deceased Date (If a parent or sibling has been lost to cancer):
*Patient's First and Last Name:
*Child's Parents / Guardians' First and Last Name:
*Patient or Child Street Address:
*City:
State:
Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland and Labrador
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Price Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
*Zip:
Home Phone:
*Cell Phone:
Work Phone:
Place Of Employment (Mother / Guardian):
Place Of Employment (Father / Guardian):
*Primary e-mail address:
*Emergency Contact:
*Emergency Phone(s):
*Patient's Date of Birth:
*Age:
*Gender:
Male
Female
T-Shirt Size (if under 18):
Child - Medium
Child - Large
Small
Medium
Large
X-Large
XX-Large
XXX-Large
*Patient's Cancer Diagnosis:
*Date Diagnosed:
Date of Relapse:
*Is patient still undergoing treatment for cancer?
Yes
No
*Patient's Primary Physician and Phone:
*Patient's Oncologist and Phone:
*Hospital where patient receives treatment:
*Insurance Carrier:
Policy Holder Date of Birth:
*Name Of Policy Holder:
*Group Policy #:
*ID #
Please list First & Last Names, Date of Birth, Gender, and Yes / No to Medical Insurance for all eligible chidren in the household under the age of 18:.
Please list any allergies or dietary needs the patient or sibling(s) may have:
Please list any special needs the patient or siblings may have:
*By selecting Yes, I hereby confirm that the details furnished above are true and correct to the best of my knowledge and I undertake to inform you of any changes therin, promptly.
Yes
Processing...
Buffalo
Syracuse
Rochester
Buffalo Newsletter
Signup
Processing...
Syracuse Newsletter
Signup
Processing...
Rochester Newsletter
Signup
Processing...
Powered by Fission
Content Management System
|
Website Design
by 360 PSG