First/Primary Adult: NEHA Family Camp Registration Form

First/Primary Adult: NEHA Family Camp Application Form 2024

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 the First/Primary Adult in your family. This should be filled out by camp participants who are the primary contact in your family. Each family attending camp needs to have a First/Primary Adult application on file for one person in their household. If you have more than one person 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.

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.
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.*
Choose a Family Identifier Name:*
Your Name:*

First NameLast Name
Email Address: *Please be sure this is typed correctly. Your verification email will be sent to THIS email address*
Primary Phone Number:*

Area CodePhone Number
Secondary Phone Number:

Area CodePhone Number
Primary Address:*

Street Address

Street Address Line 2

CityState

Zip Code
What is your gender?*

MaleFemaleNon-binaryTransgenderIntersexPrefer to describePrefer not to disclose
Please describe your gender here:
Your pronouns*

She/HerHe/HimThey/ThemPrefer not to shareOther
Which of the following best represents your 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 time of camp
Language Preference*

EnglishSpanishOther
Role within Family: Check all that apply*

MomDadSpousePartnerGrandparentFriendOther
How many years have you attended NEHA Family Camp?*

This will be my first time attending1-2 years3-5 years5 or more years
Select Camp T-shirt size: (All sizes are unisex Adult sizes)*

Extra SmallSmallMediumLargeXLXXLXXXL
Please select which type of accommodations your family will use at camp*

Cabin (provided by NEHA)RV (provided by family)Tent (provided by family)
Do you have any special accommodation requests, including accessibility, during the event?*

YESNO
Please explain accomodation request:
NEHA Family Camp is scheduled for families to arrive on Wednesday June 26, 2024 and depart on Saturday June 29, 2024. We encourage all attendees to arrive and depart on the days NEHA has scheduled, but understand some people may have extenuating circumstances. Please choose the dates that your family plans to arrive and depart from camp below.
Date your family will arrive to camp:

MonthDayYear
Date
Date your family will depart from camp:

MonthDayYear
Date
Select your mentor/mentee preference*

My family is new to NEHA Family Camp. We ARE interested in being contacted prior to camp by a seasoned family who can share their experience at camp, answer questions and welcome us to camp when we are on campus. (Agreeing means consent to having your contact information shared)My family is new to NEHA Family Camp. We ARE NOT interested in being contacted prior to camp by a seasoned family.My family is a seasoned NEHA Family Camp family. We ARE interested and would be happy to reach out to a designated new family to share our experience, answer questions, and welcome them when they are on campus.My family is a seasoned NEHA Family Camp family. We ARE NOT interested in reaching out to a designated new family.
NEHA is always looking for volunteers at Camp. If you are involved in any specialized trades such as carpentry, photography, childcare, art, etc. AND you think you would be able to volunteer some time at camp please tell us more including how much and what you would like to contribute here.
Additional Registrants
Do you have an additional adult to register for camp in your family? (Excluding Junior Counselors, Counselors, and Staff)*

YESNO
Do you have a child to register for camp in your family? (Excluding Junior Counselors, Counselors, and Staff)*

YESNO
Please list the First/Last names AND ages at camp for all additional attendees who will be attending camp in your party. (Excluding Junior Counselors, Counselors, and Staff)*
Please be sure to list ages at the start date of camp which is 6/28/23
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
Do you have any diet restrictions?*

YESNO
Diet Restrictions-Please Explain*
Do you have any activity restrictions?*

YESNO
Activity Restrictions-Please Explain*
Allergies and Medications
Do you 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 you have an EpiPen at Camp?*

YESNO
Bleeding Disorder Questionnaire

Please answer questions about this registrant only (children and additional adults will be added later)
Do you have a bleeding disorder?*

YESNO
Please check all bleeding disorders that you have here*

Factor VIII (8)Factor IX (9)VWDOther
Please explain further the severity, type, and any other notes on your bleeding disorder diagnosis here*
Please select your 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
Are you prescribed medication for your bleeding disorder?*

YESNO
Do you take this medication regularly (prophylaxis) or on-demand?*

ProphylaxisOn-DemandOther
Will you be bringing your bleeding disorder medication with you to camp?

YESNO
Please list the medication, dosage, AND frequency for all medications taken for your bleeding disorder/disorders.*
Do you have any adverse reactions to any bleeding disorder medications?*

YESNO
Please explain any adverse reactions to bleeding disorder medications*
Do you use a port, PICC line, butterfly needle or any other type of medical device to administer medications?*

YESNO
Please explain which device/devices you use for administration of medications*
butterfly needle, port, PICC line, etc.
Are you independent with infusions?*

YESNOOther
Do you self infuse?*

YESNOOther
Do you have an inhibitor?*

YESNO
Are you on Immune Tolerance Therapy*

YESNO
Please note any problem body parts or "target joints" here*
Other Medical Conditions

This section is to reference medical conditions not pertaining to a bleeding disorder
Do you have any medical conditions for which you are under the care of a doctor? (bleeding disorder aside)*

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

YESNO
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 your medical condition at camp.*
Do you have a history of major injury, illness or have you had surgery in the past year?*

YESNO
Please explain/list history here.*
Will you 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
Adult Infusion Class

Adult infusion class is for adults wishing to learn more about how to infuse themselves or their children and/or practice infusing themselves for treatment of a bleeding disorder. This class takes place while kids are in activity rotations. Adults may also use this time to learn more about injecting subcutaneous medications for a bleeding disorder.
Would you like to attend adult infusion class?*

YESNO
Do you care for a child, partner, or yourself using intravenous factor products on a prophylaxis or PRN basis? This includes anyone on a subcutaneous. non-factor replacement therapy who uses factor to treat breakthrough bleeds.*

YESNO
Have you attended this class before?*

YESNO
Do you have experience accessing your child's, a partner's, or your own port?*

YESNO
Do you have experience accessing your child's, partner's, or your own peripheral veins?*

YESNO
Are you currently independent with home treatment either for a child's, partner's, or your own bleeding disorder?*

YESNO
Special instructions or comments about attending adult infusion class.*
Insurance
Is this registrant covered by family medical/hospital insurance*

YESNO
Health Insurance Carrier*
Policy Number*
Group Number (if applicable)
NEHA Family Camp 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.
BEVAVIOR AGREEMENT:*

AGREEDISAGREE
NEHA FAMILY CAMP POLICY AUTHORIZATION

NEHA Family Camp is a drug, marijuana and alcohol free workplace. Alcoholic beverages, marijuana, and other illegal drugs are not allowed on camp grounds. Smoking tobacco is not permitted on camp grounds with campers present and is only permissible in places designated by Geneva Point Center. Disregard for this policy will constitute grounds for dismissal. I agree to follow this policy while at camp.
NEHA CAMP POLICY AUTHORIZATION:*

AGREEDISAGREE
PLEASE READ: Ground Rules for NEHA Family Camp 2024
GROUND RULES OF CAMP*

AGREEDISAGREE
PARENTAL RESPONSIBILITY AGREEMENT

I understand there will be New England Hemophilia Association (NEHA) staff as well as staff from the New England Hemophilia Treatment Centers (HTCs) at Family Camp. Nurses from the New England HTCs will be on-site providing education and basic first aid and will assist families in following physician's medical orders if their help is needed.

No hemophilia physicians will be on-site during the week. In the case of an emergency, I understand that I will need to contact my home HTC/medical provider or receive emergency care provided at a local hospital. If I cannot be located on the property, and my child needs immediate medical assistance, then I understand that an ambulance will be called to transport him/her to the nearest hospital.

I will provide factor concentrate and accompanying supplies according to instructions given per physician's orders. I will be responsible for providing bleeding disorder management for my child/children per my home treatment plan. In the event that I am not able to provide IV infusion of a factor product, I allow the nursing staff to administer the product per my physician's orders, and I will not hold the nursing staff liable for their assistance.

I agree to be fully responsible for the supervision of my child/children and any other children I have brought to Camp. This includes general supervision on the campgrounds, in and around the lake, and in our family's assigned cabin. I will, at no time, leave the camp premises without my child unless a spouse, parent or other legal guardian remains behind to take responsibility for my child/children.
PARENTAL RESPONSIBILITY AGREEMENT*

AGREEDISAGREE
RELEASE OF BLEEDING DISORDERS MEDICAL RECORDS

You, as their parent/guardian, authorize any minor child's bleeding disorder clinic, as listed on their application , 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 for the purpose of attending camp.
RELEASE OF BLEEDING DISORDERS MEDICAL RECORDS*

AGREEDISAGREEN/A
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 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 2 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:

First/Primary Adult: NEHA Family Camp Application Form 2024

Additional Registrants

Emergency Contact Information

Diet and Activity

Allergies and Medications

Bleeding Disorder Questionnaire

Other Medical Conditions

Adult Infusion Class

Insurance

NEHA Family Camp Authorizations