2026 Health Form: Child with Cancer

  • Health Form: Child with Cancer

    Must be completed by primary oncology team or primary care doctor.

  • Who is this form for?

    This form is for any child with cancer attending Happiness Is Camping's Summer Camp or Family Camp programs.

    You can also download a paper form here.

  • If you've already completed a paper health form, you can upload it here.

  • Date of Exam*
     - -
  • Date of Birth*
     - -
  • Date of Diagnosis*
     - -
  • Is the Camper on Treatment?*
  • Date Completed*
     - -
  • Did the Camper receive chemo?*
  • Did the Camper receive radiation therapy?*
  • Did the Camper receive a transplant?*
  • Does the child have a Mediport, Broviac, or VP Shunt?*
  • Does the Camper have a brain tumor?*
  • Does the Camper have a history of seizures?*
  • Varicella Status (please check all that apply)
  • Are the Camper's immunizations on hold due to treatment?*
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  • Does the Camper have diabetes?*
  • Does the Camper have asthma?*
  • Does the Camper have any known allergies?*
  • Does the Camper have a history of psychiatric or behavioral issues?*
  • Are there any Over The Counter medications that should NOT be administered at Camp?*
  • Will the Camper require any treatments while at Camp?*

  • Review of Systems

  • Rows

  • Physical Examination

  • Rows

  • Licensed Medical Personnel Authorization

  • Authorization

    I have reviewed the camper/sibling health history form and have discussed the camp program with the camper's parent or guardian. It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted above).

  • Format: (000) 000-0000.

  • **FOR CAMPERS ON TREATMENT HAPPINESS IS CAMPING WILL CONTACT YOU SEVERAL WEEKS BEFORE THE CAMP SESSION FOR AN UPDATED MEDICAL ASSESSMENT AND DETAILS OF WHAT THE CAMPER WILL NEED WHILE AT CAMP.**

  • Should be Empty: