First/Primary Adult: NEHA Family Camp Application Form 2026

  • First/Primary Adult: NEHA Family Camp Application Form 2026

    Please read all instructions carefully and complete the form below accurately.

  • We are now accepting applications for our 34th Annual Family Camp!

    The form below will only ask you information about the First/Primary Adult in your family.

    • This form should be filled out by camp participants who are the primary contact in your family.
    • Each family attending camp needs to have a First/Primary Adult application on file for one person in their household.
    • If you have more than one person who will be attending Family Camp, hit submit on the bottom of this form once you complete it, and you will be given the option to add applications for any additional adult or child in your household.
    • Although we prefer you register your entire party at one time, if you aren't able, you may hit save at the bottom of any registration. To save and continue later, you must create a Jotform Login.
    • NEHA Family Camp is intended for immediate family members. If you are registering a family member who does not reside in your household, please contact NEHA to discuss their participation at camp.
    • All Junior Counselors, Counselors, and Staff must fill out a separate application coninciding with their role at camp. Counselors, volunteers, and staff will be emailed a private link to register.

    Here are some things you should have prepared before you apply to help complete the application process in its entirety:

    1. Photos ready to upload of each camper under the age of 16
    2. Vaccination records to be uploaded for any participant registering under the age of 18
    3. Height and weight for any child under the age of 16
    4. Insurance information
    5. Treatment center information
    6. Treatment regimen information

     

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  •  What is a Family Identifier Name?

    This name will be referenced for all camp documents. Everyone who will be staying in your cabin at Camp should have the same Family Identifier Name. People will be grouped into housing accommodations based on this identifier. We suggest using your family's last name or if your family has multiple last names, using a hyphenated version of all last names within the family. Example: Pezzillo-DeGrandpre

    *The same Family Identifier Name should be used for everyone in your party who will be housing with you.*

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What is your gender?*
  • Your pronouns*
  • Which of the following best represents your racial or ethnic heritage? (Check all that apply)
  • Date of Camp
     - -
  • Primary Language*
  • Language: Please check all statements that are TRUE for you. This will help us understand how we can best communicate with you.
  • Role within Family: Check all that apply*
  • How many years have you attended NEHA Family Camp?*
  • Select Camp T-shirt size: (All sizes are unisex Adult sizes)*
  • Please select which type of accommodations your family will use at camp*
  • Do you have any special accommodation requests, including accessibility, during the event?*

  • NEHA Family Camp is scheduled for families to arrive on Wednesday June 24, 2026 and depart on Saturday June 27, 2026. We encourage all attendees to arrive and depart on the days NEHA has scheduled. Please confirm the dates that your family plans to arrive and depart from camp below.

  • Date your family will arrive to camp:*
     - -
  • Date your family will depart from camp:*
     - -
  • Select your mentor/mentee preference*
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  • NEHA Membership

  • Our Family Camp fee structure is as follows for 2026. Please read the following information carefully.

    The registration fee is $125 per family for 2026 NEHA Members at the Bronze, Silver, Gold or Diamond Levels. (Members at these levels receive a $50 discount)

    The registration fee is $175 per family for 2026 NEHA Members at the Basic Level. 

    The registration fee is $175 per family for those who are not 2026 NEHA Members.

    For families who are unable to afford the registration fee, we are happy to offer assistance through the Anneliese Seitz-Mund Scholarship, please find out more information on our Family Camp website. 

    Family Camp Registration Fees are not due until you have been notified of acceptance to camp for 2026. If you receive an acceptance to Family Camp, these fees are due by May 4, 2026.

  • What is your 2026 Membership Status?*
  • Do you plan to request a scholarship to attend NEHA Family Camp in 2026?*
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  • Additional Registrants

  • Do you have an additional adult to register for camp in your family?*
  • Do you have a child to register for camp in your family?*
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  • Emergency Contact Information

  • Format: (000) 000-0000.
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  • Diet and Activity

  • Do you have any diet restrictions?*
  • Do you have any activity restrictions?*
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  • Allergies and Medications

  • Do you have any allergies?*
  • Please Check all that apply.*
  • Do any of the above listed allergies have risk of anaphylaxis?*
  • Will you have an EpiPen at Camp?*
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  • Bleeding Disorder Questionnaire

    Please answer questions about this registrant only (children and additional adults will be added later)
  • Do you have a bleeding disorder?*
  • Please check all bleeding disorders that you have here*
  • Please select your HTC or primary hematologist.*
  • Format: (000) 000-0000.
  • Are you prescribed medication for your bleeding disorder?*
  • Do you take this medication regularly (prophylaxis) or on-demand?*
  • Will you be bringing your bleeding disorder medication with you to camp?
  • Do you have any adverse reactions to any bleeding disorder medications?*
  • Do you use a port, PICC line, butterfly needle or any other type of medical device to administer medications?*
  • Are you independent with infusions?*
  • Do you self infuse?*
  • Do you have an inhibitor?*
  • Are you on Immune Tolerance Therapy*
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  • Other Medical Conditions

    This section is to reference medical conditions not pertaining to a bleeding disorder
  • Do you have any medical conditions for which you are under the care of a doctor? (bleeding disorder aside)*
  • Will you be bringing any medications with you to camp to manage these medical conditions*
  • Are you independent with management of the medical conditions listed above and administration of any medications pertaining to those medical conditions?*
  • Do you have a history of major injury, illness or have you had surgery in the past year?*
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  • Adult Infusion Class

  • Families with bleeding disorders that require treatment with home IV therapy (regularly or intermittently) and for whom home-infusion training has been recommended by their HTC are welcome to attend this class.

    Families will learn about how to infuse themselves and/or practice self-infusing for treatment of their bleeding disorder. NEHA will communicate with treatment centers about whether infusion class is appropriate for your family. This class takes place while kids are in activity rotations so adults can focus. Adults may also use this time to learn more about injecting subcutaneous medications for a bleeding disorder.

  • Would you like to attend adult infusion class?*
  • Do you care for a child, partner, or yourself using intravenous factor products on a prophylaxis or PRN basis? This includes anyone on a subcutaneous, non-factor replacement therapy who uses factor to treat breakthrough bleeds.*
  • Have you attended this class before?*
  • Do you have experience accessing your child's, a partner's, or your own port?*
  • Do you have experience accessing your child's, partner's, or your own peripheral veins?*
  • Are you currently independent with home treatment either for a child's, partner's, or your own bleeding disorder?*
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  • Insurance

  • Is this registrant covered by family medical/hospital insurance*
  • Birth Date of Account Holder*
     - -
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  • NEHA Family Camp Authorizations

  • LIABILITY RELEASE

    I agree to indemnify and hold harmless the New England Hemophilia Association and Hemophilia Treatments Centers, and each of their employees, volunteers, officers, directors, and agents from any and all liability incurred as a result of my participation in NEHA Family Camp or in any NEHA Family Camp activity. I am aware that the activities involved with NEHA Family Camp involve the potential for injury to myself. I assume full responsibility for any loss, injury and/or inconvenience resulting from my participation. My signature below indicates that I have read and agree with the above statements

  • LIABILITY RELEASE:*

  • PHOTO RELEASE AGREEMENT

    I authorize volunteers and staff of NEHA to photograph or permit other persons to photograph the individuals listed on this sheet while at the event. I agree that NEHA may use the photos for the promotion of its educational programs, public relations activities, and other charitable purposes, and that such dissemination may be accomplished in any manner, including the NEHA website and newsletter. I understand that these photos may assist in achieving NEHA's mission and goals and hereby waive any right to compensation for such uses. The term "photograph" includes motion picture or still photography in any format, as well as videotape, videodisc, and any other mechanical means of recording and reproducing images. If I do not wish to sign this statement, I agree to personally inform the Camp Director at Camp, so that my wishes can be honored.

  • PHOTO RELEASE:*

  • BEHAVIOR AGREEMENT

    NEHA Staff and Volunteers do their best to create an open and inviting environment that children/teens can feel comfortable being a part of. It is expected that all attendees treat each other with kindness and respect while participating in one of NEHA's programs. Personal issues should be treated with discretion and any concerns should immediately be brought to the attention of a NEHA Staff Member or Volunteer who is present at the program. Bullying and cyber-bullying are prohibited at NEHA events. If an issue is reported or detected that elicits major concern, NEHA Staff will contact parents or guardians and the participants involved may be asked to leave the group. Further discussion about participation in future programs may be necessary depending on the severity of the misconduct.

  • BEVAVIOR AGREEMENT:*

  • NEHA FAMILY CAMP POLICY AUTHORIZATION

    NEHA Family Camp is a drug, marijuana and alcohol free workplace. Alcoholic beverages, marijuana, and other illegal drugs are not allowed on camp grounds. Smoking tobacco is not permitted on camp grounds with campers present and is only permissible in places designated by Geneva Point Center. Disregard for this policy will constitute grounds for dismissal. I agree to follow this policy while at camp.

  • NEHA CAMP POLICY AUTHORIZATION:*

  • PLEASE READ: Ground Rules for NEHA Family Camp 2026

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  • GROUND RULES OF CAMP*

  • PARENTAL RESPONSIBILITY AGREEMENT

    I understand there will be New England Hemophilia Association (NEHA) staff as well as staff from the New England Hemophilia Treatment Centers (HTCs) at Family Camp. Nurses from the New England HTCs will be on-site providing education and basic first aid and will assist families in following physician's medical orders if their help is needed.

    No hemophilia physicians will be on-site during the week. In the case of an emergency, I understand that I will need to contact my home HTC/medical provider or receive emergency care provided at a local hospital. If I cannot be located on the property, and my child needs immediate medical assistance, then I understand that an ambulance will be called to transport him/her to the nearest hospital.

    I will provide factor concentrate and accompanying supplies according to instructions given per physician's orders. I will be responsible for providing bleeding disorder management for my child/children per my home treatment plan. In the event that I am not able to provide IV infusion of a factor product, I allow the nursing staff to administer the product per my physician's orders, and I will not hold the nursing staff liable for their assistance.

    I agree to be fully responsible for the supervision of my child/children and any other children I have brought to Camp. This includes general supervision on the campgrounds, in and around the lake, and in our family's assigned cabin. I will, at no time, leave the camp premises without my child unless a spouse, parent or other legal guardian remains behind to take responsibility for my child/children.

     

  • PARENTAL RESPONSIBILITY AGREEMENT*

  • RELEASE OF BLEEDING DISORDERS MEDICAL RECORDS

    You, as their parent/guardian, authorize any minor child's bleeding disorder clinic, as listed on their application , to release protected health information including any relevant records pertaining to their bleeding disorder and the management of this disorder to the medical staff at NEHA Family Camp for the purpose of attending camp. You also agree to allow communication between NEHA and your HTC for the purpose of collaboration and information sharing about your attendance at camp and management of your bleeding disorder while attending camp.

  • RELEASE OF BLEEDING DISORDERS MEDICAL RECORDS*
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