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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:

*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:

T-Shirt Size (if under 18):

*Patient's Cancer Diagnosis:

*Date Diagnosed:

Date of Relapse:

*Is patient still undergoing treatment for cancer?

*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

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