2022 Camp Dragonfly

2022 Camp Dragonfly

HASDC's Annual Teen Camp for Teens Ages 14-17
Submitting a Camp Dragonfly application DOES NOT guarantee your camper a spot at camp. As space is limited, applications will be reviewed by HASDC and acceptance will be dependent on the order the application is received and that all required forms are complete, accurate, and submitted.
Please make sure you have all the required camper information, including health information and documents ready to upload, before completing the application.

You will need to provide and/or upload the following documents:
- HASDC Physicians Form: to be completed by your local HTC. Date of your child's last comprehensive visit with the HTC but be within 12-months of the first day of camp (July 8) OR completed by primary care physician (if child does not have a bleeding disorder) showing physical examination within 12-months of the first day of camp (July 8).
- Medications: complete list of medications your child takes (includes but not limited to factor, other prescription meds, over the counter medications, inhalers, etc.)
- Insurance Card: copy of your child's insurance card, front and back.
- COVID-19 Vaccination: a copy of your child's COVID-19 vaccination card (full COVID vaccination required for all campers and staff; must be fully vaccinated 2-weeks prior to camp start date).
- Immunization Records: a copy of your child's immunization records, signed and validated by your primary care physician. The following immunizations/vaccinations are required: DTap (Diphtheria/Tetanus/Pertussis), MMR (Measles/Mumps/Rubella), Measles, Varicella (chicken pox), Polio, Hepatitis A & B, and COVID-19.
- ETC Health & Liability Release: please complete this form and upload when asked in the application.

Camper Information
Camper's Full Name *

First Name Last Name
Camper is: *

a bleeding disorder patient (includes carriers) an unaffected sibling of a bleeding disorder patient
Date of Birth *

Month Day Year
Age *
Camper's Gender Identity: *

Male Female Non-Binary/Non-Conforming Transgender Other
Camper's Primary Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Camper's Cell Phone Number *
Please enter a valid phone number.
Camper's T-Shirt Size *
Is this the camper's first year at an HASDC camp? *

Yes No

Parent/Guardian Information

Provide Contact Information for Camper's Primary Guardian
Parent/Guardian (Primary Contact) *

First Name Last Name
Parent/Guardian Preferred Language *
Primary Contact's Relationship to Camper *

Mother Father Grandparent Relative Other
Primary Contact's Address (if different from Camper's)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Contact's Home Phone Number *
Please enter a valid phone number.
Primary Contact's Email *
example@example.com
Primary Contact's Cell Phone Number *
Please enter a valid phone number.

Emergency Contact Information

Not a parent/primary guardian.
Emergency Contact Name *

First Name Last Name
Relationship to Camper *
Home Phone Number *
Please enter a valid phone number.
Cell Phone Number *
Please enter a valid phone number.
Emergency Contact Primary Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Insurance Information

Provide camper's insurance information.
Camper has insurance: *

Yes No
Insurance Company
Name of Policy Holder
Insurance Company Phone Number
Please enter a valid phone number.
Policy Number
Group Number
CCS Number
MediCal Number

Healthcare Provider Information

Provide camper's healthcare provider.
Primary Care Physician
Primary Care Physician's Name *

First Name Last Name
Primary Care Physician's Phone Number *
Please enter a valid phone number.
Date of Last Physical *

Hematologist | HTC Provider

Provide hematologist information for camper's diagnosed with a bleeding disorder.
Hematologist | Hemophilia Treatment Center (HTC)
Camper is seen by a Hematologist: *
Hemophilia Treatment Center (choose one):
Hematologist's Name

First Name Last Name
Hematologist Phone Number
Please enter a valid phone number.
Date of Last HTC Visit

Medical History

Provide camper's medical history.
Bleeding Disorder Diagnosis
Factor Deficiency (choose one): *
Severity:
Does camper have an inhibitor?

Yes No
Will camper be infused the morning of camp?

Yes No
Is the camper on prophylaxis?

Yes No

Please indicate infusion dosage schedule for camp:

	Friday	Saturday	Sunday	Monday	Tuesday
Dosage (units)

Camper Form Uploads

Upload the required documents listed below.
Camper's Physical Form *

Cancel of
Camper's Insurance Card

Provide photo of front and back of card.
Cancel of
Camper's COVID-19 Vaccination Record *

Cancel of
Camper's Immunization Record *

Cancel of
ETC Health & Waiver Form *

Cancel of

Camp Consents

To be signed by camper's parent/primary guardian.
Factor Usage Consent

I want my child to use only physician-designated factor while at Camp, and I will be responsible for supplying an adequate amount of factor for the week of Camp. I understand that every reasonable effort will be made to give my child only his/her designated factor. However, I realize the possibility exists that an unusual medical emergency or situation may require that my child use donated factor, which may not be the same brand, purity or assay, and may be a plasma-derived (non-recombinant) product. If this situation occurs, I understand Camp medical staff will authorize the appropriate factor usage, which will be fully documented in my child’s medical log. I hereby release HASDC, Environmental Traveling Companions and their respective agents, employees and representatives from any claim whatsoever as a result of providing other factor.
Parent/Primary Guardian Signature

Clear
Permission to Take Photographs

I hereby give consent for photographs and/or motion pictures of my child to be used for any of the following purposes: HASDC publicity, public service announcements on television or the internet, publicity with supporting agencies, scholarship awards, camp promotion or any other agency-approved and supported activity.
Parent/Primary Guardian Signature *

Clear

Camp Dragonfly Rules

To be read with camper and signed by CAMPER.
Please be sure that you know and agree to the following camp rules before coming to camp. All campers and staff must abide by camp rules for the duration of the camping week. Campers and staff not following camp rules may be asked to leave camp and transportation must be provided by parent/primary guardian.

GENERAL
- Do not bring food, candy or drinks with you. If found, items will be confiscated.
- Electronic equipment of any kind are prohibited at camp.
- Wear shoes at all times.
- No weapons (knives, guns, sling-shots, other weapons, etc.) are ever allowed at camp at any time.
- A staff person must accompany you at all times.
- Follow the buddy system – you should ALWAYS have a buddy with you.
- You must stay on the campgrounds at all times. Leaving is not permitted.
- No visitors are allowed at any time.
- Abide by all ETC camp rules.
TENT RULES
- Stay within your assigned tent. Entering other tents is not permitted.
- Respect the space and property of others – stay out of other campers’ belongings.
- Graffiti (carved or written) is vandalism. We (you) will pay for all damages to camp property.
RESPECT
- Observe the A. D. S. rules at camp – NO Alcohol, NO Drugs, NO Sex at Camp. EVER.
- This is a non-smoking camp. No smoking is allowed anywhere on camp grounds.
- Please treat all campers and staff with respect. Teasing, swearing, inappropriate jokes and rude behavior are unacceptable - inappropriate behavior will result in contacting camper’s parent/primary guardian.
ENVIRONMENT
- Preserve the environment – throw away your garbage and recycle when possible.
- Be kind to animals – they live here, we are only visiting.
- Trees are living creatures too – please respect them by not climbing or pulling out their leaves.
Camper's Signature *

Clear

Release of Liability

To be signed by camper's parent/primary guardian.
I, First Name Last Name , am the parent/ legal guardian of a camper who will travel to and attend Camp Dragonfly (hereinafter the Camp), at Environmental Traveling Companions ("ETC"), sponsored by the Hemophilia Association of San Diego County ("HASDC"). I understand that the activities involved in Camp will pose the risk of harm or injury. On my own behalf, and on behalf of my child or ward, I hereby freely and expressly consent to release, discharge, indemnify and hold harmless the Hemophilia Association of San Diego County, and their respective agents, employees, and representatives from any damage, claims, loss, or injury sustained by me or my child/ward while traveling to or from the Camp, while attending or participating in any activities at Camp, or any other trips or activities sponsored by the Hemophilia Association of San Diego County. This release includes within its scope any damage, loss or injury sustained as a result of any ordinary negligence, whether active or passive on the part of the Hemophilia Association of San Diego County, or any of their respective agents, employees or representatives.

As the parent/guardian of the camper, I hereby give my consent to any medical treatment, including any examination, X-ray, anesthetic, medical or surgical diagnosis or treatment, or hospital care to be rendered to me or my child/ward under the general or special provisions of the Medical Practice Act, or to consent to any dental treatment, including any examination, X-ray, anesthetic, dental or surgical diagnosis or treatment, or hospital care to be rendered to me or my child/ward by a dentist licensed under the provisions of the Dental Practice Act. This authorization shall be effective while I or my child/ward is en-route to or from Camp, or involved or participating in any program or activity of Camp, or under the supervision of any personnel associated with the Camp, regardless of the location where treatment or care is rendered, unless earlier revoked by me in writing and delivered to the Hemophilia Association of San Diego County.

The foregoing release is to be construed in accordance with the laws of the State of California. It is intended to release claims, which are not yet known. Accordingly, I hereby waive, on my own behalf, and on behalf of my child/ward, the provisions of California Civil Code §1542, which provides:

“A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor.”

I have read and understood this Release and Authorization and the information I have given is true and correct.
Parent/Primary Guardian Signature *

Clear

Camp Dragonfly Application Fee

All camper's must pay the $25 application fee.

Camper Application Fee

USD Description

Credit Card

Should be Empty:

2022 Camp Dragonfly

Camper Information

Parent/Guardian Information

Emergency Contact Information

Insurance Information

Healthcare Provider Information

Primary Care Physician

Hematologist | HTC Provider

Hematologist | Hemophilia Treatment Center (HTC)

Medical History

Bleeding Disorder Diagnosis

Medical Information

Allergies

Psychosocial

Other Medical Conditions

Additional Questions

Medication Information

Camper Form Uploads

Camp Consents

Factor Usage Consent

Permission to Take Photographs

Camp Dragonfly Rules

Release of Liability

Camp Dragonfly Application Fee

Credit Card

	Medication Name	Dose	Fri	Sat	Sun	Mon	Tue	As Needed
1
2
3
4
5
6
7
8
9
10