Camp Good Days

Eligible Camper's Name:

*Street Address:

*City:

State:

*Zip:

Region:

	Buffalo		Rochester
	Syracuse		Out-Of-State

*Phone:

*Email:

Have you ever attended a Women's Oncology Program with Camp Good Days?

*T-Shirt Size Camper

*Date of Birth:

Gender - Camper

Diagnosis:

Diagnosis Date:

Date or Year of Relapse:

Date of Last Treatment:

*Name Of Spouse / Support Person:

*Email - Spouse / Support Person:

*Date of Birth - Spouse / Support Person:

Gender - Spouse:

T-Shirt Size Spouse

MEDICAL INSURANCE INFORMATION (Required To Attend Camp Good Days)

*Health Insurance Carrier:

Policy Holder:

*Policy #:

Group ID #

Additional Insurance Information (if family members have different policies):