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NEW FAMILY YEAR-ROUND APPLICATION

This application is available to any child or adult who is currently being or has been treated for cancer or sickle cell anemia and their immediate family members without regard to race, color, gender, gender identity or expression, religion, national origin, or sexual orientation. Camp Good Days strives to foster a safe, supportive and inclusive community environment for children, adults and family members to be surrounded by those who are experiencing similar life challenges.

Final acceptance into Camp Good Days’ programs shall be determined after review. Only one application is needed per family.

Eligibility Guidelines

Camp Good Days offers programs for children (ages 4-17), adults (18+) and families including:

Children who have been diagnosed with cancer or sickle cell anemia
Children that have a parent or sibling who has been diagnosed with cancer or sickle cell anemia
Children that have lost a parent or sibling with cancer or sickle cell anemia
Adults with Cancer

If you know an adult, child or family that would qualify for our programs refer them here.

* Denotes A Required Field

Camp Good Days has offices in Western NY, Central NY and the Finger Lakes region.

Please select the regional office closest to your home address.

ONCOLOGY/HEMATOLOGY PATIENT INFORMATION

* Patient's First Name:

* Patient's Last Name:

Chosen / Preferred Name:

* Date of Birth:

* Gender:

Pronouns:

*Primary Language:

Secondary Language:

*Patient's Oncology / Hematology Diagnosis:

*DATE OF DIAGNOSIS

Patient's Secondary (Onc/Hem) Diagnosis:

MEDICAL CENTER WHERE PATIENT WAS TREATED

* Name Of Facility:

*Physician (Specialist):

Physician Telephone:

Social Worker:

Social Worker Telephone:

*Is Patient Deceased?

Yes

Date Deceased:

Date of Relapse (if Applicable):

Date of Last Treatment (if no longer in treatment);

FAMILY CONTACT INFORMATION

Parent/Legal Guardian #1/Or Patients 18+ (This person will be used as the primary contact person. Mailings, both email and postal mail will be sent to this address)

* First Name:

*Last Name:

Pronouns:

*Relationship To Participants:

*Address:

*City:

State:

*Zip Code:

* Email:

* Mobile Phone:

Employer:

Work / Home Phone:

* Primary Language:

Secondary Language:

PARENT/LEGAL GUARDIAN #2

First Name:

Last Name:

Pronouns:

Relationship to Participants:

Email:

Mobile Phone:

Employer:

Work / Home Phone:

Primary Language:

Secondary Language:

Marital Status (please indicate marital status of parents and explain any familial circumstances and/or custodial arrangements of which we should be aware):

EMERGENCY CONTACT INFORMATION

This person will be contacted if Parent/ Legal Guardian(s) cannot be reached.

* Emergency Contact Name:

* Relationship to Participant:

* Phone:

* Alternate Phone Number:

ADDITIONAL ELIGIBLE PARTICIPANTS

(Note: Household Members who qualify for our programs)

INDIVIDUAL 1

Child's Name:

Chosen / Preferred Name:

Relationship To HEM / ONC Patient:

Date Of Birth:

Gender:

Pronouns:

INDIVIDUAL 2

Child's Name:

Chosen / Preferred Name:

Relationship To HEM / ONC Patient:

Date Of Birth:

Gender:

Pronouns:

INDIVIDUAL 3

Child's Name:

Chosen / Preferred Name:

Relationship to HEM / ONC Patient:

Date Of Birth:

Gender:

Pronouns:

INDIVIDUAL 4

Child's Name:

Chosen / Preferred Name:

Relationship To HEM / ONC Patient:

Date Of Birth:

Gender:

Pronouns:

HEALTH INSURANCE INFORMATION

Health Insurance (required to attend Camp Good Days programs)

* Health Insurance Company:

* Policy Holder:

* Policy Number:

* Group Number:

Additional Insurance Information: Please list information here if family members have different policies:

ADDITIONAL INFORMATION

T-Shirt Size (indicate if child or adult size):

Please list any physical limitations the participant(s) may have:

Please list any allergies or dietary restrictions the participant(s) may have:

Please list any special needs or medical needs the participant(s) may have:

Anything Else We Should Know:

How did you find out about Camp Good Days programs and services?

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