HH Summer 2024 Interest Form

1
Hospital Name/Health Organization Name* This field is required.
2
Group Coordinator Name* This field is required.
First Name
Last Name
3
E-mail* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
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
6
Are you interested in sending an organized group of camper's to Double H this summer?* This field is required.
YES
NO
7
If no, please encourage your families to apply for Summer 2025. Applications should be available in late January. If a camper needs assistance with transportation, please have them contact the Admissions Office directly.
8
How many camper's is your group intereseted in sending to Double H this summer?Esitmated number
9
Medical diagnoses of camper's within the group* This field is required.
Sickle Cell Anemia
Hemophilia
Juvenile Arthritis
Oncology
Neuromuscular Disorders
Other Bleeding Disorders
Mitochondrial Disorders
GI Disorders
Solid Organ/Visceral Transplant
Congenital Cardiac Defects
Immune Disorders
Rare Disorders
Endocrine Disorders
Other
10
Does your group need financial assistance with transportation to and from camp this summer?
YESNO
11
The group WILL provide a chaperone(s) that will ride the bus with the camper's to and from camp.* This field is required.
YES
NO
12
The group WILL provide a volunteer(s) to stay for the camp session as a volunteer nurse or volunteer cabin counselor? Please provide the volunteer position.* This field is required.
Volunteer Nurse
Volunteer Cabin Counselor
Unable to provide a session volunteer
13
If known, please provide name(s) of potential volunteer(s).
14
Session dates for group in order of preference* This field is required.Drag and drop into preference order. We appreciate your flexibility with scheduling.
15
Please let us know if you have any additional information or questions for the Admissions Office.
Should be Empty: