Camp Crescent Moon Summer Camp Registration Form 2023

CAMP CRESCENT MOON APPLICATION 2023
Camp Crescent Moon is for children ages 7-14 with SICKLE CELL DISEASE
APPLICATION DUE DATE: THURSDAY, JUNE 1st

** APPLICATION MUST BE FILLED OUT AND SUBMITTED ONLINE **

DO NOT PRINT THIS APPLICATION

COVID-19 Safety and Vaccination Requirements:

Proof of Covid-19 Vaccination is required to apply!

Proof of COVID-19 vaccination is required for ALL campers and must be submitted with this application.

Unfortunately, if your child has not started the Covid-19 vaccination series by March 1, 2023, they will not be eligible to attend camp due to the vaccination schedule and the inability to complete the primary covid-19 vaccination by the start of camp.

See Covid-19 Vaccination Timing Schedule - Schedule if Moderately or Serverly compromised (page 2)
Health History/Physical Due by June 1st:

Please call your child's doctor as soon as possible to schedule a physical exam. The information we need must be current. We will request an update on your child's health status from his/her doctor before camp.
NEED HELP??

IF YOU HAVE QUESTIONS about this application, about required paperwork, or need further assistance, please contact the Sickle Cell Disease Foundation at 909-743-5226 or send an email to camps@scdfc.org.
Estimated time to fill out the application:

The application will take about 20 minutes. Please fill out ENTIRELY. One application per child. Fill out and submit ONLINE ONLY. **DO NOT PRINT AND SCAN.**

If you do not have Internet access - please find someone to help you fill this out online. If you're worried about your computer crashing or the app not going through, save answers as you go along in a Word Document and copy and paste them into the application.

You can also email us at camps@scdfc.org if you need help with the application.
ITEMS TO UPLOAD AT THE END OF THE APPLICATION:
1. COVID-19 Vaccination Card
2. CURRENT PHOTO: Please upload a current JPG photo of this child at the end of the app.
3. MEDICAL INSURANCE CARD: Please upload a copy of your child's insurance card at the end of the app.
REGISTRATION FEE - $50:

Deposit of $10.00 - Due by June 15, 2023

Balance of $40.00 - Due by July 15, 2023

You may pay with cash, check, debit/credit card, PayPal, or money order.

CHECKS AND MONEY ORDERS SHOULD BE MADE OUT TO:

Sickle Cell Disease Foundation.

Mail to: SCDF Camp Crescent Moon, 3602 Inland Empire Blvd., Suite C315, Ontario, CA 91764

Waiver Program available: Please email camps@scdfc.org
Name of Person Filling Out This Application*

First NameLast Name
Relationship to Child*
I understand that due to the covid-19 policy, there is limited space at camp this year and that there is no guarantee that my child will get a space at camp. Notifications will go out in early June.*

Yes I understand
I understand that proof of covid-19 vaccination is required to submit application.*

Yes I understand
How many Covid-19 vaccine doses has your child completed?*
For information, please email camps@scdfc.org
If your child has had one (1) covid-19 vaccine, when is the next dose scheduled?
If your child has had two (2) covid-19 vaccines, when is the next dose scheduled?
Child's Information
Child's Name*

First NameLast Name
Preferred Name (if child has one)*
Gender*
For Other, how does your child identify?
Birthdate*

MonthDayYear
Age at Time of Camp (July 15-22nd)*
Current Grade in School*
Child's SCD Diagnosis*

SS (Sickle Cell Anemia)SC (Sickle Cell C Disease)S-Thal (Sickle Beta Thalassemia)SD (Sickle Cell D Disease)SE (Sickle Cell E Disease)Unknown
Child's T-shirt size*
We cannot offer a child small due to the artwork placement on the shirt.
Child's Primary Language:*

EnglishSpanish
Parent/Guardian Information
Who does camper live with? check all that apply*

MotherFatherStepmotherStepfatherGrandmotherGrandfatherBrother(s)Sister(s)Cousin(s)
Who has legal custody of the camper?*

Both ParentsMotherFather
Mailing Address (for camp related mail)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent or Legal Guardian #1*

First NameLast Name
Relationship to Child*
Best Phone Number*

Area CodePhone Number
This phone number is a:*

Cell PhoneWork PhoneHome Phone (land line)
Texts Accepted?*
Parent/Guardian #1 Email Address*
example@example.com
Parent/Guardian #1 Second Email Address (if you have one)
example@example.com
Parent/Guardian #1 Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent or Legal Guardian #2

First NameLast Name
Relationship to Child
Parent or Legal Guardian #2 Best Phone Number

Area CodePhone Number
This phone number is a:

Cell PhoneWork PhoneHome Phone (land line)
Texts Accepted?
Parent/Guardian #2 Second Email Address (if you have one)
example@example.com
Parent/Guardian #2 Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information

I authorize the following persons to be contacted and give my permission to turn my child over to these individuals if for any reason my child has to leave camp and I CANNOT BE REACHED (please do not list yourself).
FIRST adult authorized (age 18+) to pick up this child from Camp Crescent Moon if you cannot be reached. **Government ID will be required at pick up***

First NameLast Name
Cell Number for Authorized Adult #1*

Area CodePhone Number
Relationship to child:*
SECOND adult authorized (age 18+) to pick up this child from Camp Crescent Moon if you cannot be reached. **Government ID will be required at pick up***

First NameLast Name
Cell Number For Authorized Adult #2*

Area CodePhone Number
Relationship to child:*
Medical Insurance & Doctor Information
Insurance Company:*
Phone Number:

Area CodePhone Number
Policy/Group Number:*
Name of Insured:*

First NameLast Name
Relationship to Camper:*
CCS number (if applicable):
Medi-Cal number (if applicable):
Name of Child's Doctor or Nurse:*
Phone Number

Area CodePhone Number
Medical Center/Hospital: *
Camper Information

Please fill this out to the best of your ability. We want to make sure your child has a safe, healthy, fun time at camp. This information is extremely helpful!
Has your child attended Camp Crescent Moon before?*
Has your child attended any other resident/sleepover camp before?*
If yes, name of camp:
Has your child ever been away from home or family members for more than 5 days?*
How does your child feel about going to camp? Hopes, fears, concerns, etc.*
Why would your child's attendance at Camp Crescent Moon be important? Why would you like your child to attend camp?*
How did you learn about Camp Crescent Moon?*

From the Sickle Cell Disease FoundationDoctor or NurseInternet search
Do you have transportation to drop off and pick up your child at the campsite in Pacific Palisades?*

YesNoUnsure
List all known allergies to food, plants, medications, animals, etc.*
Food Restrictions:*

NoneNo beefNo porkVegetarianLactose Intolerant
Does your child have nose bleeds?*

NoYes, sometimesYes, frequently
Child's sleeping habits (check all that apply)*

Average sleeperLight sleeperHeavy sleeperTalks in sleepSleepwalksFalls out of bedNightmares
Does your child wet the bed at night?*

Never wets the bedRarely wets the bedFrequently wets the bedWets the bed every night
If your child does wet the bed, please explain (i.e. wears pull-ups, not drinking liquids after certain time, just needs to be aware, etc.)
How many times per week does your child have a bowel movement?*
What is your child's attention span?*

Terrific attention spanAttention constantly needs redirectingVery short attention span
Please let us know if any of the following learning difficulties exist for your child.*

Hearing impairmentVision impairment (that would affect time at camp)Dyslexia or reading difficultiesDon't know about learning difficultiesNone
If these learning difficulties will negatively affect this camper's week at camp - or if this information would help us make camp better for your child - please explain.
For girls/children assigned Female at birth ONLY:
Has your child started her period?
If yes, will your child have her period at camp?
Does your child have menstrual cramps?
If YES, does she take any kind of medications for the menstrual cramps?
List medication for menstrual cramps:
HISTORY/STORY: Please share your child's history or story so we can understand how to give them an even MORE amazing week at camp!

Please be as honest as you can
Please let us know strengths and great, positive things about your child. Please write as much as you'd like!*
Please tell us what this child's interests, passions, loves, etc. are so our Staff can make camp even more special! (i.e. Loves sports, interested in horses, favorite color is purple...whatever!)*
How does your child spend his/her free time?*
In what situations does your child feel least comfortable?*
Does your child have any usual behaviors or fears? If yes, please describe below:*
Is your child afraid of the following?:*

BugsDogsThe DarkNone
Does your child tend to: (check all that apply):*

WanderDaydreamUse foul languageRunawayNone
What kinds of challenges may your child's camp counselor most likely encounter from your child? What is the best way to resolve them?*
Any additional information you need for our staff or counselors to know while your child is up at camp?*
How would you like to receive the physical form and teacher questionnaire? They are available to print below*
Each camper is required to have a physical form completed by the doctor and a teacher questionnaire completed by his/her teacher.
How would you like to receive the camp liability forms? They are available to print below.*
Each camper is required to have the liability forms below.
Please download the Emergency Treatment Release Form, Teacher Questionnaire and Health History/Physical BELOW.

There are six pages. Your child's teacher must complete the teacher questionnaire, and your child's doctor/nurse must complete the physical.

Be sure to send all back with ORIGINAL signatures by June 1st.

Please mail to

SCDF Camp Crescent Moon,

3602 Inland Empire Blvd., Suite C315, Ontario, CA 91764.

You can also fax the forms to (909) 743-5227.
To download the forms, click on the arrow icon next to printer icon (on the right)
Would you like to participate in the Camp Walkathon on Saturday, May 6th at the campsite in Pacific Palisades? *
Camp Deposit/Registration Fee (can pay online or mail it to us) - The fee is refundable *
prevnext( X )
I will mail the deposit of $10 by June 15th $ Free
Check or Money Order - Due by June 15th

I will pay the deposit of $10 online by June 15th$10.00
Online payment of deposit only - due by June 15th

I am paying the full camp registration fee of $50 online with the application$50.00
Online payment of full registration fee - Due by July 15th

I may need assistance with the registration fee & I will contact the camp program. $50.00

Quantity

Total $0.00
Comments/Questions/Concerns:
How would you rate completing this online application to the paper application?*
**REQUIRED Uploads** JPG ONLY...do NOT upload a PDF or other file type **
Please upload a copy of your CHILD'S COVID-19 Vaccincation Record..do NOT upload a PDF or other file type **. You will not be able to upload an image larger than 1 MB (or 1024 KB) in size.*

Upload a File

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Please upload a recent color photo of this child (within the last six months). Upload a JPG ONLY...do NOT upload a PDF or other file type **. You will not be able to upload a photo larger than 1 MB (or 1024 KB) in size.*

Upload a File

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Please upload a copy of your CHILD'S MEDICAL INSURANCE CARD. Upload a JPG ONLY...do NOT upload a PDF or other file type **. You will not be able to upload an image larger than 1 MB (or 1024 KB) in size.

Upload a File

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If Available please upload the following items below:
Upload a copy of CHILD'S SECOND INSURANCE CARD. You will not be able to upload a photo larger than 1 MB (or 1024 KB) in size.

Upload a File

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Upload a copy of child's IMMUNIZATION RECORD. You will not be able to upload a photo larger than 1 MB (or 1024 KB) in size.

Upload a File

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Upload a copy of child's PHYSICAL (must include both sides). You will not be able to upload a photo larger than 1 MB (or 1024 KB) in size.

Upload a File

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Upload a copy of child's TEACHER QUESTIONNAIRE. You will not be able to upload a photo larger than 1 MB (or 1024 KB) in size.

Upload a File

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Upload a copy of child's LIABILITY/RELEASE FORMS. You will not be able to upload a photo larger than 1 MB (or 1024 KB) in size.

Upload a File

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APPLICATION CHECKLIST
Checklist for this Online Application: Check that you have ALL items needed to complete this application.

ONLINE APP: Completely filled out online camp application submitted online. (Please do NOT print this application. It is important to have all information stored online and not in paper form.)MEDICAL/INSURANCE COPY: Copy of insurance card mailed to SCDFDEPOSIT/PARTIAL APPLICATION FEE: $10 check or money order PER CHILD made out to SCDF, mail to 3602 Inland Empire Blvd., C315, Ontario, CA 91764FULL APPLICATION FEE: $50 check or money order PER CHILD made out to SCDF, mail to 3602 Inland Empire Blvd., C315, Ontario, CA 91764CHILD'S PHYSICAL: Copy of latest physical mailed to ATTN: SCDF Camp Crescent Moon, 3602 Inland Empire Blvd., C315, Ontario, CA 91764RELEASE FORM PAGES: Printed and obtained proper signatures for 6-page PDF Release Forms for CCM 2023 (available at link above).COPY OF SHOT RECORD: Please send a copy of the child's shot/immunization/vaccination records.Copy of Covid-19 vaccination record.
Please hit red submit button below upon completion of the application*

Application will be submitted when you hit the red submit button below.
For office use only
notes/comments
Should be Empty:

Child's Information

Parent/Guardian Information

Emergency Contact Information

Medical Insurance & Doctor Information

Camper Information

For girls/children assigned Female at birth ONLY:

HISTORY/STORY: Please share your child's history or story so we can understand how to give them an even MORE amazing week at camp!

**REQUIRED Uploads** JPG ONLY...do NOT upload a PDF or other file type **

If Available please upload the following items below:

APPLICATION CHECKLIST

REQUIRED Uploads JPG ONLY...do NOT upload a PDF or other file type **