Secondary Adult: NEHA Family Camp Application Form 2026

  • Secondary 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 ask you information about a secondary adult in your household who will be applying for camp and are NOT the primary contact for your application.
    • 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 adults or children 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.
    • 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.
    • 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.

     

     

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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 Camo 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 this adult's gender?*
  • Adult pronouns*
  • Which of the following best represents this adult's 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 has this registrant attended NEHA Family Camp?*
  • Select Camp T-shirt size: (All sizes are unisex Adult sizes)*
  • Do you have any special accommodation requests, including accessibility, during the event?*
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  • Emergency Contact Information

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

  • Does this registrant have any diet restrictions?*
  • Does this registrant have any activity restrictions?*
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  • Allergies and Medications

  • Does this registrant have any allergies?*
  • Please Check all that apply.*
  • Do any of the above listed allergies have risk of anaphylaxis?*
  • Will this adult have an EpiPen with them at camp?*
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  • Bleeding Disorder Questionnaire

    Please answer questions about this registrant only
  • Does this registrant have a bleeding disorder?*
  • Please check all bleeding disorders that apply*
  • Please select this registrant's HTC or primary hematologist.*
  • Format: (000) 000-0000.
  • Is this registrant prescribed medication for their bleeding disorder?*
  • Does this registrant take their medication regularly (prophylaxis) or on-demand?*
  • Will this registrant be bringing any bleeding disorder medication with them to camp?
  • Does this registrant have any adverse reactions to any bleeding disorder medications?*
  • Does this registrant use a port, PICC line, butterfly needle or any other type of medical device to administer medications?*
  • Is this registrant independent with infusions?*
  • Does this registrant self infuse?*
  • Does this registrant have an inhibitor?*
  • Is this registrant on Immune Tolerance Therapy*
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  • Other Medical Conditions

    This section is to reference medical conditions not pertaining to a bleeding disorder
  • Does this registrant have any medical conditions for which they are under the care of a doctor? (bleeding disorder aside)*
  • Will this registrant be bringing any medications with them to camp to manage these medical conditions*
  • Is this registrant independent with management of the medical conditions listed above and administration of any medications pertaining to those medical conditions?*
  • Does this registrant have a history of major injury, illness, or have they 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 this registrant like to attend adult infusion class?*
  • Does this registrant care for a child, partner, or themselves 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.*
  • Has this registrant attended this class before?*
  • Does this registrant have experience accessing their child's, partner's or their own port?*
  • Does this registrant have experience accessing their child's, partner's or their own peripheral veins?*
  • Is this registrant currently independent with home treatment either for their child's, partner's or their own bleeding disorder?*
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  • Insurance

  • Is this registrant covered by the same family medical/hospital insurance as the Primary Adult who applied with this Family Identifier name?*
  • Is this registrant covered by medical/hospital insurance?*
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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

    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 agree to 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.

  • BEHAVIOR 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 included in this registration packet. 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*
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