Apply for Family Camp!

This application is only to attend our Family Camp program scheduled for August 15-18, 2023. If you are looking to register your child for an overnight or day Camp, please see the Summer Camp page on our website for links to those applications.

Our 2023 Family Camp is open to any family with a child or parent diagnosed with cancer or sickle cell anemia since 2020 and/or any family who has lost a parent or child with cancer or sickle cell since 2020. New participants and children or adults currently in treatment will be given priority.

Applicants are accepted into Camp Good Days programs free of charge, without regard to race, ethnicity, gender, gender identity or expression, religion, national origin, disability, or sexual orientation. Final acceptance shall be determined upon review.

* Denotes A Required Field

FAMILY INFORMATION

*Family Name:

* # of attending adults (18+):

* # of attending children (Birth-17):

*Home Address:

*City:

State:

*Zip Code

Have you/your child(ren) ever attended a summer camp session with Camp Good Days?

Have you/your child(ren) ever attended a year-round program with Camp Good Days?

*Nearest Camp Good Days Office:

	Buffalo		Rochester		Syracuse
	Out of State

*Primary Language:

PATIENT INFORMATION

(If your family has more than one patient, please contact Alicia Sommer)

*Patient Name:

*Diagnosis:

Patient Date of Birth:

*Patient Age:

Patient Gender:

*Date of Diagnosis:

*Is patient currently recieving treatment?:

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

Date of Last Relapse (if applicable)

Date of Death (if applicable):

*Medical Center (where patient is/was treated):

CAMP PARTICIPANTS

Please list all participants who will be attending the session

Parents/Guardians

Are responsible for the actions and supervision of each child/participant throughout the program. At least one legal parent or guardian is required to attend.

*Parent / Guardian 1 (required):

Parent/Guardian Date of Birth

*Email:

*Phone #:

All communication regarding the session will be sent to this contact (i.e. e-mail and postal mail).

*Relationship to Patient:

Parent / Guardian 2:

Parent/Guardian 2 Date of Birth

E-Mail:

Phone #:

Relationship To Patient:

Additional Adults

Please list any other adult (18 and older) living in your household who will be attending camp

Adult (not parent):

Adult (not parent) Date of Birth

Relationship to Patient:

Children

Please list all dependent children (age birth to 17) attending the session

Child 1

Child's Name:

Gender:

Date Of Birth:

Age:

Relationship to Patient:

Child 2

Child's Name:

Gender:

Date Of Birth:

Age:

Relationship to Patient:

Child 3

Child's Name:

Gender:

Date Of Birth:

Age:

Relationship to Patient:

Child 4

Child's Name:

Gender:

Date Of Birth:

Age:

Relationship to Patient:

Child 5

Child's Name:

Gender:

Birth Date:

Age:

Relationship to Patient:

Child 6

Child's Name:

Gender:

Birth Date:

Age:

Relationship to Patient:

(If your family has more than 6 children, please email the requested additional child information to: Alicia Sommer)

HOUSING

Families will have the option to either (1) be assigned to our gendered cabins, either boy or girl cabin or (2) share an assigned cabin with 1-3 other families. Our cabins are generally one large room with bunks, with a restroom off of it. There are not separate sleeping spaces. We will do our best to assign you to your preferred housing type. See the family information packet for more details.

*Please select your preferred housing:

	Assign housing by gender
	Assign housing as a family in shared cabin
	Do not have a preference

If you know another family attending that you would like to share a space with, please provide their last name.

Apply for Family Camp!

(If your family has more than one patient, please contact Alicia Sommer)

All communication regarding the session will be sent to this contact (i.e. e-mail and postal mail).

(If your family has more than 6 children, please email the requested additional child information to: Alicia Sommer)

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