Family Camp History Form

Family Camp History Form

For attendees of Family Camp.
This form is required for families attending Oncology or Sickle Cell Family Camp.

You will need your medical insurance information (if applicable), including policy and group numbers, in order to complete this form.
Oncology Family CampSickle Cell Family Camp
Please list the names of all attendees. Please separate each name with a comma.*
Please upload a picture of your child(ren) with cancer/sickle cell disease.*

This photo will allow our medical volunteers to easily identify your child. Please make sure their face is clearly visible.
Cancelof

Allergies
YesNo
List allergy and reaction details, date, and description*
YesNo
Please provide their name and details about their anaphylaxis, including the date and description of the reaction*
YesNo

Dietary Restrictions
YesNo
Please provide their name(s), allergies, and any dietary restrictions.*
Our chef is capable of providing for most allergy-related dietary restrictions.

Insurance Information
Family Doctor Name*
Name of Pediatrician
Family Doctor Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Full Name of Policy Holder*
Policy Holder Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Employer Name (if insured through company)
Insurance Company / Plan Name*
Insurance Company Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Health Insurance Policy Number*
Insurance Group Name or Number*

Waivers & Consent
Medical Waiver (must read)

This health history is correct and accurately reflects the health status of the individuals to whom it pertains. The persons described have permission to participate in all camp activities except as noted above by an examining licensed medical professional. I give permission to the licensed medical professional selected by the camp to order x-rays, routine tests, and treatment related to the health of the individual for both routine health care and in emergency situations, including distributing over-the-counter medications. If I cannot be reached in an emergency, I give my permission to the licensed medical professional to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for the individual. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of the described individual’s health record from providers who treat them and these providers may talk with the program's staff about the described individual’s health status.
I agree to the above statement.
Media Wiaver (must read)

Full permission and authority is granted to Happiness Is Camping, Inc. and its representatives to photograph or video members of my family and to use, publish, and release for publication such as photos, videos, etc. relating to the program of Happiness Is Camping, Inc. The name of such persons photographed may be used in connection with the above, with the understanding that there will be no exploitation of the camper and that any photographs used should conform to standards of good taste. Third-party groups providing programs/services at Happiness Is Camping may use photos/videos of campers with express written consent of Happiness Is Camping, Inc. and must abide by the above.

I hereby release and discharge Happiness Is Camping, Inc. and its Board of Directors and any and all other parties in interests from all claims, demands, grievances, and causes of action of every kind whatsoever, including but not limited to, all liability for damages of every kind, nature, or description which may arise from or out of any injury incurred by my family while in attendance at the camp or enroute to or from the camp.
I agree to the above statement.
Assumption of Risk and Liability Waiver (must read)

I understand that part of the camping experience involves activities and group living arrangements and interactions that may be new to my family, and that they come with certain risks and uncertainties beyond what my family may be used to dealing with at home. I am aware of these risks, and I am assuming them on behalf of my family. I realize that no environment is risk-free, and so I have instructed my family on the importance of abiding by the camp’s rules and will obey them.

It is agreed that any dispute or cause of action arising between the parties, whether out of this agreement or otherwise, can only be brought in a court of competent jurisdiction located in Warren Country, New Jersey, and shall be constructed in accordance with the laws of New Jersey.”
I agree to the above statement.
Your Name*

First NameLast Name
Your Email*
example@example.com
Your Signature*

Clear
Should be Empty:

Family Camp History Form

Allergies

Dietary Restrictions

Family Health History

Insurance Information

Waivers & Consent

Medical Waiver (must read)

Media Wiaver (must read)

Assumption of Risk and Liability Waiver (must read)