Family Camp Interest Form

1
Your name* This field is required.
First Name
Last Name
2
Your email* This field is required.
example@example.com
3
Your cell phone number* This field is required.
Please enter a valid phone number.
4
Your relationship to the camper(s)* This field is required.
Parent/Primary Caregiver
Grandparent
Extended Family
Family Friend
Other
5
If you are not the primary caregiver, please provide their name and contact information below.
6
Your race/ethnicity
American Indian or Alaska Native
Asian
Black or African American
Middle Eastern
Native Hawaiian or Other Pacific Islander
White
Other
7
The first* camper's name is    First Name *     Last Name * .

Their current age is    Number *    .

Their gender identity is

Their race/ethnicity is      *

*If you have another camper to add, the next section will allow you to add their info individually
8
Do you have another camper to add?* This field is required.
YESNO
9
The second* camper's name is    First Name *     Last Name * .

Their current age is    Number *    .

Their gender identity is    Female     Male     Non-binary *

Their race/ethnicity is      *

*If you have another camper to add, the next section will allow you to add their info individually
10
Do you have another camper to add?
YESNO
11
The third* camper's name is    First Name *     Last Name * .

Their current age is    Number *   .

Their gender identity is    Female     Male     Non-binary *

Their race/ethnicity is    *

*If you have another camper to add, the next section will allow you to add their info individually
12
Do you have another camper to add?
YESNO
13
The fourth* camper's name is    First Name *     Last Name * .

Their current age is    Number *    .

Their gender identity is    Female     Male     Non-binary *

Their race/ethnicity is    *

*If you have another camper to add, the next section will allow you to add their info individually
14
Do you have another camper to add?
YESNO
15
The fifth* camper's name is    First Name *     Last Name * .

Their current age is    Number *    .

Their gender identity is    Female     Male     Non-binary

Their race/ethnicity is

*If you have more campers to add, complete this form and send the additional information to familycamp@experiencecamps.org
16
Have any of the campers previously attended an Experience Camps program?* This field is required.Family Camp is open to new families and campers currently enrolled in our one-week programs
Yes, at least one camper is currently enrolled in a week-long program
Yes, at least one camper is currently waitlisted for a week-long program
Yes, at least one camper has previously attended ExCamps in the past
No, none of the campers have applied or attended any other ExCamps program
17
Please list the name(s) of the camper(s) who have previously attended or are waitlisted for another ExCamps program.
18
Does your family live in the city of Philadelphia?* This field is required.
YESNO
19
Where does the family live (physical address)?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
20
Who is the person that died? (What is their relationship to the camper?)* This field is required.You may choose multiple options if it applies.
Parent
Primary Caregiver
Sibling
Grandparent
Extended Family Member
21
When did this person(s) die?* This field is required.We recommend campers wait to attend camp at least 4-6 months from the date of the persons death.
22
The first adult's name is    First Name *     Last Name * .

Their age is    Number *    .

Their gender identity is    Male     Female     Non-binary *   .

Their relationship to the family is    Text * .
23
Do you have another adult to add?* This field is required.
YESNO
24
The second adult's name is    First Name *     Last Name * .

Their age is    Number * .

Their gender identity is    Male     Female     Non-binary * .

Their relationship to the family is    Text * .
25
Is English the primary household language?* This field is required.
YESNO
26
Please provide more information on languages spoken in the family:
27
Do any family members applying for camp use a mobility device or have any physical limitations?* This field is required.
YESNO
28
Please provide more information on physical mobility limitations or restrictions.
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Large
Normal
Small
Ok
Ok
29
What is your family looking to gain from attending Family Camp?
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Ok
Ok
30
Have any of the family members participated in other grief support/services? If so, please briefly describe that experience.
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Ok
31
How did you hear about us?* This field is required.
Should be Empty: