Junior Counselor: NEHA Family Camp Registration Form

Junior Counselor: 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!

This application is intended only for NEHA Family Camp JUNIOR Counselors aged 16 or 17 at the time of camp. Junior Counselors should not register under Staff.

Copies of submissions will be emailed to you. Although we prefer you register 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.
What is a Family Identifier Name?

This name will be referenced for all camp documents. Junior Counselors and Parents/Guardians should have the same Family Identifier Name. Please communicate with your family to be sure your Family Identifier Name matches theirs. Junior Counselors will be grouped into rooming accommodations based on this identifier. Junior Counselors will be housing with their parent/guardian as in past years. 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:*
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 Fluency (Check all that apply)*

EnglishSpanishOther
Name of your Parent/Guardian who will be attending camp:*

First NameLast Name
Is your address the same as your Parent/Guardian who will be attending camp?*

YESNO
Address of Parent Guardian who will be attending camp:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Parent/Guardian who will be attending camp:*

Area CodePhone Number
Email of Parent/Guardian who will be attending camp:*
example@example.com
Select Camp T-shirt size: (All sizes are unisex Adult sizes)*

Extra SmallSmallMediumLargeXLXXLXXXL
How many years have you attended NEHA Family Camp?*
How many years have you been a junior counselor at NEHA Family Camp?*

This is my first year applying to be a junior counselor1 year2 years
NEHA Family Camp is scheduled for Junior Counselors to arrive on Tuesday June 25, 2024 and depart on Saturday June 29, 2024. All junior counselors will need to arrive and depart on the days NEHA has scheduled, but we understand some people may have extenuating circumstances. Please choose the dates that you plan to arrive and depart from camp below.
Date you will arrive to camp:

MonthDayYear
Date
Date you will depart from camp:

MonthDayYear
Date
If known, please share any information on which color groups you have worked with in the past and/or which ages of children you prefer or do not prefer to work with. *NEHA does NOT guarantee that they can accommodate age or color group requests.*
Please explain your experience and/or strengths you feel you can bring to the color group.
Additional Registrants
Do you have any additional family members who will be registering for camp?*

YESNO
Please list the First/Last names AND ages at camp for all additional attendees who will be attending camp in your family. *
Please be sure to list ages at the start date of camp which is 6/22/22
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 with you 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*
By typing my name here, I and my parent/guardian, authorize the bleeding disorder clinic, as listed on this application , to release protected health information including any relevant records pertaining to my bleeding disorder and the management of this disorder to the medical staff at NEHA Family Camp for the purpose of attending camp.*
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
Are you up to date on all other immunizations?*

YESNO
Please upload documentation of your immunizations: Alternatively, you may email immunization records to info@newenglandhemophilia.org or fax them to 781.329.5122 by May 5, 2023.

Browse Files

Cancelof
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.
BEHAVIOR 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 2022
GROUND RULES FOR CAMP*

AGREEDISAGREE
**Family Camp Volunteer and Staff Code of Conduct**

I wish to participate as a volunteer/counselor/staff member at Family Camp. In accepting this position, I accept the responsibility to carry out the duties assigned to me to the best of my abilities and to abide by the Family Camp rules and policies. I understand that while I am at Family Camp, I am a role model for the children and will conduct myself accordingly. I also agree: To ensure a safe, fun and meaningful camp experience, NEHA Family Camp expects all staff to adhere to certain rules of conduct. By signing the acceptance of this agreement you agree to follow the rules listed here.

1. Staff members are expected to have fun. With camper safety first and foremost in our minds, laugh, play, sing, and dance till you can no more. Enjoy this experience.

2. Communicate openly. In order to maintain the best work environment possible, staff members are expected to be approachable, listen to their coworkers, and respect all others at camp. Work toward solutions. It’s more productive than dwelling on problems. Talk to the Camp Director who is Program Director of NEHA whenever you have an issue that you need assistance with during camp.

3. Staff members are expected to be appropriate role models for campers at all times. This does not mean to thwart individuality, but be aware of the fact that you’re taking care of impressionable children. Think about whether or not you would participate in a behavior in front of a camper’s parents.

4. Staff will supervise campers in a way that encourages campers’ independence, dignity, and safety.

5. Staff needs to treat all camper information as confidential and to only use such information in a professional manner. Information about a camper’s medical condition cannot be used for personal gain.

6. Camper disclosure of any child abuse (sexual, physical, or neglect) or suicidal indication must be reported immediately to the NEHA Executive Director or Camp Director.

7. Abuse of campers by a staff member is forbidden. Disregard of this policy is grounds for immediate dismissal and will be reported to local authorities. Any staff member observing the behavior of another that is considered abusive must report this to camp administration immediately. NEHA has a policy of “One Strike and You’re Out”.

8. For the protection of all campers, staff, volunteers, and visitors, NEHA Family Camp does not allow isolated one-to-one interaction between a staff/volunteer and child inside any closed room, vehicle, bathroom, shower stall or any area that could be considered private. In all cases, there should be at least 3 in a group with a staff member and a camper.

9. Sexual harassment is not allowed. (Title VII of the Civil Rights of 1964) It is against policy for any employee or volunteer, male or female, to sexually harass other employees/volunteers. Staff who believe they are victims of sexual harassment should immediately contact NEHA’s ED.

10. Smoking tobacco is not permitted on camp grounds with campers present and is only permissible in places designated by Geneva Point Center. Smoking marijuana is not permitted on camp grounds at all. Disregard for this policy will constitute grounds for dismissal. NEHA Family Camp is a drug, marijuana, and alcohol-free workplace. Alcoholic beverages, marijuana, other forms of narcotics whether prescribed or not and other illegal drugs are not allowed on camp grounds. Staff on prescribed narcotics will store such medication in the infirmary. Staff is not permitted on grounds if they appear under the influence of any drugs, appear impaired, or are legally intoxicated. Disregard of this policy constitutes grounds for immediate dismissal.

11. All staff must turn over all medications to the Medical staff for storage while camp is in session. This includes aspirin and over the counter medications or vitamins.

12. Personal financial transactions between any staff member and a camper are not allowed.

13. Staff members are not to leave camp grounds at any time while camp is in session without the permission of the Camp Directors.

14. No personal visitors when camp is in session. Visitors may not visit areas where campers are present unless special permission is received from the Camp Director.

15. Staff should not receive phone calls during working hours except in the case of emergencies.

16. For the safety of all, staff members are not allowed to use the waterfront, campfire, or GPC facilities, without proper supervision and permission.

17. Camp property is not to be removed from the grounds for personal use.

18. NEHA Family Camp is not responsible for damaged, lost or stolen personal items. It is strongly recommended that whenever possible all valuables (money, jewelry, passports, etc.), be left at home or locked in the nursing office.

19. Gross misconduct is staff behavior that warrants the immediate termination without following the steps of progressive discipline. Examples are violent behavior, abuse, neglect, exploitation of campers, using drugs or alcohol or being under their influence while on camp grounds, extreme insubordination, gross neglect of duties, sexual harassment and other forms of harassment. Should there be a disagreement over the interpretation of camp policies or a grievance related to one’s duties or relationships with staff members, it is to be reported to the ED of NEHA promptly.

20. Staff members may not have in their possession or on the camp property: firearms, slingshots, fireworks, and any types of weapons, excepting utility/camp knives used in conjunction with camp activities.

21. Relationships with campers should be friendly and supportive. Staff members may never become romantic, intimate, suggestive, or sexual with a camper.

22. Relationships with other staff members should be friendly and supportive. Staff members may never become intimate, suggestive or sexual with each other while at camp. Staff relationships may not interfere with any camp responsibilities.

23. Staff members are expected to be at all scheduled activities on time, alert, and prepared.

24. Staff must be free of physical or psychological conditions that might adversely affect children’s physical or mental health. If in doubt, an expert should be consulted.

25. Profanity, inappropriate jokes, sharing intimate details of one’s personal life, and any kind of harassment in the presence of children or parents is prohibited.

26. Staff members and volunteers will adhere to all COVID-19 rules and protocols as set forth by NEHA and Geneva Point Center. I understand that Family Camp leaders have the authority to dismiss those who do not follow these policies.
STAFF CODE OF CONDUCT*

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 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:

Junior Counselor: NEHA Family Camp Application Form 2024

Additional Registrants

Emergency Contact Information

Diet and Activity

Allergies and Medications

Bleeding Disorder Questionnaire

Other Medical Conditions

Insurance

NEHA Family Camp Authorizations