CHILD: NEHA Family Camp Registration Form

Child: NEHA Family Camp Application Form

Please read all instructions carefully and complete the form below accurately.
We are now accepting applications for our 32nd Annual Family Camp!

The form below will only ask you information about one of your children. If you have more than one child who will be attending Family Camp, hit submit on the bottom of this form once you complete it, and you will be given the option to add applications for any additional adults or child in your household. Please note, you must also add an application for any adults attending Family Camp (including yourself).

Copies of submissions will be emailed to you. Although we prefer you register your entire party at one time, if you aren't able, you may hit save at the bottom of any registration. To save and continue later you must create a Jotform login.

All Junior Counselors, Counselors, and Staff must fill out a separate application coninciding with their role at camp.
Child Name:*

First NameLast Name
What is a Family Identifier Name?

This name will be referenced for all camp documents. Children and Parents/Guardians should have the same Family Identifier Name. People will be grouped into housing accommodations based on this identifier. If you are registering for another family, please submit a separate form and choose a different Family Identifier Name to ensure they get their own accommodations. We suggest using your family's last name or if your family has multiple last names, using a hyphenated version of all last names within the family. Example: Pezzillo-Degrandpre

*The same Family Identifier Name should be used for everyone in your party who will be housing with you.*
Family Identifier Name:*
We will be sharing photos of all campers with their counselors so they can easily identify everyone in their group once they arrive at camp. In this next section you have the option to either take a photo in real time OR upload a photo you have already taken.
Upload a photo of this child

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What is this child's gender?*

MaleFemaleNon-binaryTransgenderIntersexPrefer to describePrefer not to disclose
Please describe this child's gender here:
Child's pronouns*

She, Her, HersHe, Him, HisThey, Them, TheirsPrefer not to shareOther
Which of the following best represents this child's racial or ethnic heritage? (Check all that apply)

Alaska Native or American IndianAsianBlack or African AmericanHispanic or Latino NativeHawaiian or Other Pacific IslanderWhiteOther/Multi Ethnic
Birth Date:*

MonthDayYear
Date of Camp

MonthDayYear
Date
Camp Date-Birth Date
Age at Camp
Language Preference*

EnglishSpanishOther
Role within Family: Check all that apply*

Child with bleeding disorderSibling of child with bleeding disorderChild of an adult with a bleeding disorderChild of a volunteer or staffOther
List Name(s) of any parents/guardians who will be at camp with this child:*
Email Address of Parent/Guardian attending camp: Please be sure this is typed correctly. Your verification email will be sent to THIS email address*
Phone Number of Parent/Guardian who will be attending camp:*

Area CodePhone Number
Secondary Parent/ Guardian Phone Number:

Area CodePhone Number
How many years has this child attended NEHA Family Camp?*

This will be my first time attending1-2 years3-5 years5 or more years
Child's Height:*
Child's Weight:*
Is this child's address the same as the First/Primary Adult who registered with this family identifier name?*

YesNo
Primary Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Select Camp T-shirt size:*

Youth Extra SmallYouth SmallYouth MediumYouth LargeYouth Extra LargeAdult Extra SmallAdult SmallAdult MediumAdult LargeAdult XLAdult XXLAdult XXXL
If known, please share the name of ONE friend in the bleeding disorders community who this child wishes to be grouped with: *NEHA does NOT guarantee that they can accommodate all buddy requests. All buddy requests should be no more than a year older or younger than this child.*
Emergency Contact Information
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone Number:*

Area CodePhone Number
Emergency Contact Email
example@example.com
Relationship to Registrant:*
Diet and Activity
Does this child have any dietary restrictions?*

YesNo
Diet Restrictions-Please Explain*
Does this child have any activity restrictions?*

YesNo
Activity Restrictions-Please Explain*
Please indicate this child's swim level:*

BeginnerIntermediateAdvanced
By typing your full name here, its confirms that you understand the importance of water safety and that your child is allowed at the waterfront and will be under the supervision of yourself or a NEHA counselor.*
Type your full name here to mark your signature.
Allergies and Medications
Does this child have any allergies?*

YesNo
Please Check all that apply.*

FoodMedicationEnvironmental
Please list any allergies indicated above and reactions for each:*
Do any of the above listed allergies have risk of anaphylaxis?*

YesNo
Please indicate which allergies listed above have risk of anaphylaxis.*
Will this child have an EpiPen with them at camp?*

YesNo
Bleeding Disorder Questionnaire

Please answer questions about this child/registrant only
Does this child have a bleeding disorder?*

YesNo
Has this child already received their Big Stick Award from NEHA Family Camp?*

YesNoNot Sure
Please check all bleeding disorders that this child has here*

Factor VIII (8)Factor IX (9)VWDOther
Please explain further the severity, type, and any other notes on this child's bleeding disorder diagnosis here*
Please select this child's HTC or primary hematologist.*

Boston Hemophilia Center (Brigham and Women's)Boston Children'sConnecticut Children's Hemophilia CenterDartmouth-HitchcockMaine Hemophilia Treatment Center (Scarborough)Maine Hemophilia Treatment Center (Bangor)Massachusetts General HospitalNew England Hemophilia Center (UMASS Memorial Hospital)Rhode Island Hemophilia CenterTufts Children's HospitalUCONN Hemophilia CenterVermont Regional Hemophilia CenterYale New Haven Hemophilia CenterOther
Primary Hematologist Phone Number*

Area CodePhone Number
Primary Hematologist Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is this child prescribed medication for their bleeding disorder?*

YesNo
Does this child take this medication regularly (prophylaxis) or on-demand?*

ProphylaxisOn-DemandOther
Will you be bringing this child's bleeding disorders medications with you to camp?*

YesNo
Please list the medication, dosage, AND frequency for all medications taken for this child's bleeding disorder/disorders.*
Does this child have any adverse reactions to any bleeding disorder medications?*

YesNo
Please explain any adverse reactions to bleeding disorder medications*
Does this child use a port, PICC line, butterfly needle or any other type of medical device to administer medications?*

YesNo
Please explain which device/devices this child uses for administration of medications*
butterfly needle, port, PICC line, etc.
Is this child and/or their family independent with infusions?*

YesNoOther
Does this child self infuse?*

YesNoOther
Does this child have an inhibitor?*

YesNo
Is this child on Immune Tolerance Therapy*

YesNo
Please note any problem body parts or "target joints" here
By typing your full name here, you authorize this child's bleeding disorder clinic, as listed above, to release protected health information including any relevant records pertaining to their bleeding disorder and the management of this disorder to the medical staff at NEHA Family Camp.*
Type your full name here to mark your signature.
Other Medical Conditions

This section is to reference medical conditions NOT pertaining to a bleeding disorder
Does this child have any medical conditions (bleeding disorder aside) for which they have seen a medical professional? (including behavioral or learning differences)*

YesNo
Please explain these medical conditions.*
Will your family be bringing any medications with you to camp to manage these medical conditions*

YesN0
Please list any medications you will be bringing, dosage, and frequency of use.*
Are you independent with management of the medical conditions listed above and administration of any medications pertaining to those medical conditions?*

YesNo
Please explain what support you will need to manage this medical condition at camp.*
Does this child have a history of major injury, illness or have they had surgery in the past year?*

YesNo
Please explain/list history here.*
Does this child struggle with transitions between activities, caregivers, schedules, etc?*

YesNo
Details:*
Please also include any helpful tips for getting to know this child including interests, favorites, etc.
Does this child tend to be nervous or shy in new environments?*

YesNo
Details:*
Please include any helpful tips for getting to know this child including interests, favorites, etc.
Share anything you would like NEHA's Family Camp Counselors to know about this child. Please include strengths, interests, strategies that help if your child is struggling at camp (i.e. jokes, quiet time, one on one, favorite stuffed animal etc.), and/or anything else you believe could help smooth your child's process of attending camp.
Immunizations
Will this child be fully vaccinated with the COVID-19 vaccine by June 26, 2024? (Vaccination is not required to attend Family Camp but helpful for Medical Staff to know in the case sickness occurs at camp.)*

YesNo
Is this child up to date on all other immunizations?*

YesNo
Please upload documentation of child's immunizations: Alternatively, you may email immunization records to info@newenglandhemophilia.org or fax them to 781-329-5122 by April 1, 2024.

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Child Self Infusion Class

Child Self Infusion Class is for children wishing to learn more about how to infuse themselves and/or practice infusing themselves for treatment of a bleeding disorder. Children may also use this time to learn more about injecting subcutaneous medications for a bleeding disorder.
Would you like this child to attend child self infusion class?*

YesNo
Has this child attended this class before?*

YesNo
Does this child have experience administering bleeding disorder medication?*

YesNo
Does this child have experience gathering and setting up medical supplies to treat their bleeding disorder?*

YesNo
Special instructions or comments about this child's experience with self infusion training and treatment of their bleeding disorder.*
By typing your full name here, you confirm that you understand your child may participate in self infusion class during camp which includes using needles, medical supplies, and could cause injury.*
Type your full name here to mark your signature.
Insurance
Is this child covered by the Same family medical/hospital insurance as the Primary Adult registered with this Family Identifier name?*

YesNo
Is this registrant covered by family medical/hospital insurance*

YesNo
Health Insurance Carrier*
Policy Number*
Group Number (if applicable)
Authorizations
LIABILITY RELEASE

I agree to indemnify and hold harmless the New England Hemophilia Association and Hemophilia Treatments Centers, and each of their employees, volunteers, officers, directors, and agents from any and all liability incurred as a result of my participation in NEHA Family Camp or in any NEHA Family Camp activity. I am aware that the activities involved with NEHA Family Camp involve the potential for injury to myself. I assume full responsibility for any loss, injury and/or inconvenience resulting from my participation. My signature below indicates that I have read and agree with the above statements
LIABILITY RELEASE*

AGREEDISAGREE
PHOTO RELEASE AGREEMENT

I authorize volunteers and staff of NEHA to photograph or permit other persons to photograph the individuals listed on this sheet while at the event. I agree that NEHA may use the photos for the promotion of its educational programs, public relations activities, and other charitable purposes, and that such dissemination may be accomplished in any manner, including the NEHA website and newsletter. I understand that these photos may assist in achieving NEHA's mission and goals and hereby waive any right to compensation for such uses. The term "photograph" includes motion picture or still photography in any format, as well as videotape, videodisc, and any other mechanical means of recording and reproducing images. If I do not wish to sign this statement, I agree to personally inform the Camp Director at Camp, so that my wishes can be honored.
PHOTO RELEASE:*

AGREEDISAGREE
BEHAVIOR AGREEMENT

NEHA Staff and Volunteers do their best to create an open and inviting environment that children/teens can feel comfortable being a part of. It is expected that all attendees treat each other with kindness and respect while participating in one of NEHA's programs. Personal issues should be treated with discretion and any concerns should immediately be brought to the attention of a NEHA Staff Member or Volunteer who is present at the program. Bullying and cyber-bullying are prohibited at NEHA events. If an issue is reported or detected that elicits major concern, NEHA Staff will contact parents or guardians and the participants involved may be asked to leave the group. Further discussion about participation in future programs may be necessary depending on the severity of the misconduct.
BEHAVIOR AGREEMENT:*

AGREEDISAGREE
IMMUNIZATIONS ATTESTATION

You can upload documentation of child's immunizations on the "Immunizations" section of this form. Alternatively, you may email immunization records to info@newenglandhemophilia.org or fax them to 781-329-5122.

I attest that this child is up to date on all immunizations and will submit documentation to verify this statement by April 1, 2024 (not including COVID-19 Vaccine)
IMMUNIZATIONS ATTESTATION*

AGREEDISAGREE
COVID-19 PROTOCOL AGREEMENT

Please read all COVID-19 rules and protocols as set forth by NEHA and Geneva Point Center prior to arriving at Family Camp. These rules and protocols are subject to change and is dependent on the continuously evolving nature of the Pandemic. NEHA will share exact rules and protocols within two weeks of your arrival at Camp.
I agree to read and follow all guidelines set forth by NEHA and Geneva Point Center while at camp.*

AGREEDISAGREE
By typing your full name here you confirm that all above authorizations listed in this registration have been completed accurately.*
Typing your full name here marks your signature.
Should be Empty:

Child: NEHA Family Camp Application Form

Emergency Contact Information

Diet and Activity

Allergies and Medications

Bleeding Disorder Questionnaire

Other Medical Conditions

Immunizations

Child Self Infusion Class

Insurance

Authorizations