Camp Good Days

FAMILY CAMP 2021 APPLICATION FORM

This application is available to any family who has (or has lost) a parent or child who has been or is in treatment for cancer or sickle cell anemia within the last FIVE years. Families outside of five years will be put on a wait-list. New participants and children or adults currently in treatment will be given priority. Due to limitations of space and overall capacity, only children or adults living in the same household are eligible to attend.

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.

Please Note: Each accepted family is required to attend a virtual information session prior to arrival. You will need your health insurance information to complete this form.

* Denotes a Required Field

CAMP INFORMATION

*Which Camp Are You Registering For?

New Family camp

Camp Courage

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.

(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)

Buffalo Newsletter Signup

Syracuse Newsletter Signup

Rochester Newsletter Signup

Connect With Us