2025 Campers (7-14)- Camp Hemotion Application

Camp Hemotion 2025 Campers (Ages 7-14)

Welcome back to HFNC's Annual Summer Camp! – Inspiring the Leaders of Tomorrow –
Getting Started & Information
- Please set aside approximately 30 minutes to complete the application.
- Ensure you have all necessary information about your child ready before beginning your application, including health details and required documents.
- If you are registering multiple children, please note that a separate application must be submitted for each child individually.
- Submitting a Camp Hemotion application does not guarantee a spot at camp.
- Space is limited and HFNC will review applications in the order they are received.
- Acceptance will depend on availability and whether all required forms are complete, accurate, and submitted on time.
  If you have any questions or need assistance filling out your child's application, please email outreach@hemofoundation.org for assistance. (Se habla español).
  
  Important Note for Central California Hemophilia Foundation (CCHF) Applicants:
  If you live outside HFNC’s 20-county service area (click here for the full list), you can still apply to attend Camp Hemotion. However, the Central California Hemophilia Foundation (CCHF) will review your application separately and decide if they will help cover the camp fee for applicants in their area.
Application Deadline: Friday, May 30th
To submit your child's application to Camp Hemotion 2025, these four steps must be completed:
1. Complete and sign this Camp Hemotion application here. This includes:
  - Medications: Provide a complete list of your child’s medications, including (but not limited to) factor, prescription medications, over-the-counter medications, and inhalers.
  - Health Insurance Cards: Provide a photocopy (front and back) of your child’s insurance card(s).
  - Immunization Records: Provide a copy of your child’s immunization records, signed and validated by a healthcare provider.
    
    The following immunizations are required. Failure to provide proof of all listed immunizations may result in the forfeiture of your child’s application:
    
    - DTaP (Diphtheria, Tetanus, Pertussis)
    - DTaP Booster (7th Grade or higher)
    - MMR (Measles, Mumps, Rubella)
    - Varicella (Chickenpox)
    - Polio
    - Hepatitis B
2. Have your child's Healthcare Provider fill and sign the Healthcare Provider form.
3. Have your child's school teacher fill and sign the Teacher Questionnaire.
4. Fill out and sign the Camp Oakhurst Medical Release Form.

Camper Information
Camper's Full Name*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
Camper's Gender Identity:*

MaleFemaleNon-Binary/Non-ConformingTransgenderOther
Camper's Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Camper's T-Shirt Size*
(kid sizes)
Is This the Camper's First Year at an HFNC Camp?*

YesNo
Grade entering in Fall 2025:*
Bus Transportation:
Camper Pick-Up Location*
Camper Return Location*

Please list any siblings and/or relatives attending camp:

	First Name	Last Name	Age	Relationship to Camper
Attendee 1
Attendee 2

Emergency Contact Information

Not a parent/ primary guardian.
Emergency Contact Name*

First NameLast Name
Relationship to Camper*
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Communication Methods (select all that apply)*

Home PhoneCell Phone
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Emergency Contact's Email*
example@example.com

Insurance Information

Provide camper's insurance information
Camper has insurance*

YesNo (HFNC will contact you privately for follow-up)
Insurance Company*
Name of Policy Holder*
Insurance Company Phone Number*
Please enter a valid phone number.
Policy Number*
Group Number*
CCS Number
MediCal Number
Camper's Insurance Card: Upload FRONT AND BACK of card(s):*

Please upload the FRONT AND BACK of the requested documents. Multiple files can be uploaded in the box above.
Cancelof

Healthcare Provider Information

Provide camper's healthcare provider.
Primary Care Physician
Primary Care Physician's Name*

First NameLast Name
Primary Care Physician's Phone Number*
Please enter a valid phone number.
Date of Last Physical*

MonthDayYear
Date

Hematologist | HTC Provider

Provide Hematologist information for camper diagnosed with a bleeding disorder.
Hemophilia Treatment Center (HTC)
Camper is seen by a Hematologist*

YesNo
Hemophilia Treatment Center*

Stanford University Medical CenterUCSF Benioff Children's Hospital OaklandUC DavisUC San FranciscoValley Children's HospitalOther
Hematologist Name*

First NameLast Name
Hematologist Phone Number*
Please enter a valid phone number.
Date of Last HTC Visit

MonthDayYear
Date

Required Camper Forms

All forms must be submitted by Friday, May 30th.
- Camp acceptance is contingent upon the submission of these documents.
- It is the parent's responsibility to ensure that all required forms are completed, signed, and submitted to HFNC before finalizing the application.
- Incomplete or unsubmitted forms may result in delays or forfeiture of the application.
Form 1. 2025 Camp Hemotion Healthcare Provider Form

Copy the link above and send it to your child's Healthcare Provider to complete & sign the form online.

OR

Click here to Download and complete the form offline.

Email the form back to outreach@hemofoundation.org with file titled: "FirstName-LastName-2025-Camp Hemotion Camper Healthcare Provider Form".
- Your child must have had a check-up at the HTC within 12 months prior to the first day of camp.
- If your child does not have a bleeding disorder but is a sibling of someone with a bleeding disorder (residing in the same household), their primary care doctor must still complete this form.
Form 2. 2025 Camp Hemotion Teacher Questionnaire

Copy the link above and send it to your child's School Teacher to complete & sign the form online.

OR

Click here to Download and complete the form offline.

Email back to outreach@hemofoundation.org with file titled: "FirstName-LastName-2025 Camp Hemotion Teacher Questionnaire".
- This form is essential for helping our counselors provide the best support and guidance for your camper.
Form 3. 2025 Oakhurst Health & Release Form

Click the link above to complete and sign yourself.

OR

Click here to DOWNLOAD and complete the form offline.

Email back to outreach@hemofoundation.org with file titled "FirstName-LastName-2025 Oakhurst Health Release Form".
- This liability form is required by our campgrounds host, Camp Oakhurst.

Authorizations and Consent for Treatment

I, the undersigned parent/guardian, give permission for my child to participate in all camp activities designed for his/her age group. I further authorize Hemophilia Foundation of Northern California & Camp Oakhurst as agent for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under general or special supervision of any physician and surgeon licensed under the provisions of the medicine practices act on the medical sta of local hospitals whether such a diagnosis or treatment. is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his/her best judgment may deem advisable. This authorization is given in pursuant to the provisions of Section 25.8 of the Civil Code of California.
Signature*

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MEDICAL RELEASE: This health history is correct so far as I know and this person has the permission of the undersigned to engage in all camp activities except as noted. In the case of illness or injury, Hemophilia Foundation of Northern California and Camp Oakhurst has my permission to procure medical treatment for the above named (minor, if applicable). I understand Hemophilia Foundation of Northern California and Camp Oakhurst does not provide medical insurance or reimbursement for medical fees or prescriptions and that I am responsible for any / all such fees and charges arising from illness or injury that may occur.

LIABILITY RELEASE: The undersigned, for himself or herself and on behalf of his or her child(ren) or ward(s) and their personal representatives assigns or heirs, (hereinafter referred to as Releasors,) hereby releases and agrees and covenants not to sue Hemophilia Foundation of Northern California and Camp Oakhurst, their owners, directors, stockholders, agents, successors, or any employee, (hereinafter referred to as Releasees,) from any and all liability for loss, damage, injury, death, or any other claim whatever to the person or property of any guest or participant whether caused by negligence of Releasees or any other person or thing while participating in activities sponsored by or associated with Hemophilia Foundation of Northern California and Camp Oakhurst The undersigned elects to participate and/or allow his or her child(ren), ward(s) to participate voluntarily and assumes all risk of loss, damage, injury or death, known or unknown, foreseen or unforeseen, that may be sustained.

YOU HAVE THE OPTION NOT TO PARTICIPATE OR ALLOW YOUR CHILD, CHILDREN, WARD OR WARDS, NOT TO PARTICIPATE, IN ANY ACTIVITY WHERE YOU DO NOT WISH TO WAIVE LIABILITY. IT SHALL BE YOUR RESPONSIBILITY TO INSURE THAT YOUR CHILD, CHILDREN, WARD OR WARDS DO(ES) NOT PARTICIPATE IN THE ACTIVITIES FOR WHICH YOU CHOOSE NOT TO BEAR LIABILITY.

The undersigned has read and voluntarily signs this medical release and waiver of all liability.
Signature*

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Indemnification Authorization:
Media Release: I agree that the Hemophilia Foundation of Northern California (HFNC) may use, re-use, publish, or re-publish in whole or in part, individually or in conjunction with others, my image or my child’s image in any medium and/or for any purpose whatsoever, including but not limited to illustration, promotion, website, and/or advertising trade. I further release the Hemophilia Foundation of Northern California (HFNC), its Board, its officers and representatives from any and all claims of any nature arising from any medium and/or publication.

Signature of Participant or Parent/Guardian if under 18
Signature*

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Camp Hemotion Admission Portal
Camp Hemotion Cost, Support, and Camp Value

Camp Cost: HFNC offers its flagship program, Camp Hemotion, for FREE to the community. We believe that no child should ever miss out on camp due to financial challenges, and to send your child to camp is a meaningful decision.

Camp Support: Your Contribution Makes a Difference!

It costs the chapter $1,650 per child to attend the full week at camp. Therefore, we are kindly requesting a contribution to your child's experience at camp, and ensures that this special opportunity remains available for all children in our community.

Your support ensures Camp Hemotion keeps running, improves our programming, and maintains program and medical supplies. The full cost of camp represents more than just a weekend away—it’s an investment in a safe, enriching, and unforgettable experience for our kids.

Camp Value: Camp offers tremendous value to a child's growth and the community as a whole. Most campers, staff, and camp alumni agree that Camp Hemotion is an incredible and life-changing experience.

Here are some key values that Camp Hemotion offers:
- Gaining independence by learning how to self treat their bleeding disorder
- Learning more about their (or their sibling's) bleeding disorder(s)
- Experiencing new skills like swimming, archery, rock climbing, hiking, and stage performing (camp skits and talent show)
- Opportunities to play various sports in a safe environment
- Learning more about nature and their environment
- Learning how to socialize and make new lifelong friendships
Your support helps cover essentials like:
- Three nutritious meals a day plus snacks during non-meal hours
- Bus transportation
- Engaging activities led by trained Camp Staff
- Comfortable accommodations in cabins that have heating and AC
- It also provides for professional, trained medical staff who dedicate their time to ensuring every child’s health and safety throughout the weekend. Every dollar you contribute helps create a secure, supportive environment where kids can build confidence, forge lifelong friendships, and experience the magic of camp. Your generosity makes this life-changing experience possible—thank you for investing in their future.
Thank you for being part of the HFNC family. We’re excited to create unforgettable memories at Camp Hemotion 2025 with your child!

Warmly,
The HFNC Team

Please choose a payment option to secure your child's spot at Camp Hemotion:*

Option 1: Camper Contribution Product Image

Option 1: Camper ContributionI would like to contribute a set amount toward my child's camp attendance.

$25.00 Contribution Amount:
Item subtotal:$0.00

Option 2- Financial Aid Request Product Image

Option 2- Financial Aid RequestI am requesting full financial aid for my child to attend Camp Hemotion. Please provide an explanation below.

$ Free

Total

$0.00

Payment Methods

Credit Card

ACH Bank Transfer

We’d appreciate a brief paragraph about your selected option above. Your input helps us better understand our community's challenges and allocate funding to support those who need it most. Thank you for your help!*
If you prefer not to provide a response, please enter N/A in the box above.
We sincerely thank you for being a part of our community and for helping keep Camp Hemotion thriving!

We’ll see you at camp!
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Camp Hemotion 2025 Campers (Ages 7-14)

Getting Started & Information

To submit your child's application to Camp Hemotion 2025, these four steps must be completed:

Camper Information

Parent/ Guardian Information

Emergency Contact Information

Insurance Information

Healthcare Provider Information

General Medical Information

Medication Information

Immunization Records

Bleeding Disorder Information

Hematologist | HTC Provider

Bleeding Disorder Medical History

Required Camper Forms

Camp Hemotion Admission Portal

Camp Hemotion Cost, Support, and Camp Value

Payment Methods