Child: NEHA Family Camp Application Form 2026

Child: 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 one of your children.
- If you have more than one child 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.
- Please note, NEHA needs a separate application submitted for each member of your family who wishes to attend camp.
- 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. Child Height & Weight
4. Insurance information
5. Treatment center information
6. Treatment regimen information
Child Name:

First NameLast Name
Child Preferred Name:
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.*
Family Identifier Name:
Camper Photos

We will be sharing photos of all campers with their counselors so they can easily identify everyone in their group once they arrive at camp. In this next section you have the option to either take a photo in real time OR upload a photo you have already taken.

We HIGHLY recommend uploading a photo so camp counselors can do their best to identify all children and help them feel comfortable.
Upload a photo of this child

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What is this child's gender?
Please describe this child's gender here:
Child's pronouns

Other
Which of the following best represents this child's racial or ethnic heritage? (Check all that apply)
Birth Date:

MonthDayYear
Date of Camp

MonthDayYear
Date
Camp Date-Birth Date
Age at Camp
Language Preference

Other
Language: Please check all statements that are TRUE for this child. This will help us understand how we can best communicate with this child.
Role within Family: Check all that apply

Other
List Name(s) of any parents/guardians who will be at camp with this child:
Email Address of Parent/Guardian attending camp: Please be sure this is typed correctly. Your verification email will be sent to THIS email address
example@example.com
Phone Number of Parent/Guardian who will be attending camp:
Format: (000) 000-0000.
Secondary Parent/ Guardian Phone Number:
Format: (000) 000-0000.
Primary Address:

Street Address

Street Address Line 2

CityState

Zip Code
How many years has this child attended NEHA Family Camp?
Child's Height:
Child's Weight:
Select Camp T-shirt size:
If known, please share the names of friends in the bleeding disorders community who this child wishes to be grouped with: *NEHA does NOT guarantee that they can accommodate buddy requests. All buddy requests should be no more than a year older or younger than this child.*
Emergency Contact Information
Emergency Contact Name:

First NameLast Name
Emergency Contact Phone Number:
Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Relationship to Registrant:
Diet and Activity
Does this child have any dietary restrictions?
Diet Restrictions-Please Explain
Does this child have any activity restrictions?
Activity Restrictions-Please Explain
Please indicate this child's swim level:
By typing your full name here, its confirms that you understand the importance of water safety and that your child is allowed at the waterfront and will be under the supervision of yourself or a NEHA counselor.
Type your full name here to mark your signature.
Allergies and Medications
Does this child have any allergies?
Please Check all that apply.
Please list any allergies indicated above and reactions for each:
Do any of the above listed allergies have risk of anaphylaxis?
Please indicate which allergies listed above have risk of anaphylaxis.
Will this child have an EpiPen with them at camp?
Bleeding Disorder Questionnaire

Please answer questions about this child/registrant only
Does this child have a bleeding disorder?
Has this child already received their Big Stick Award from NEHA Family Camp?
Please check all bleeding disorders that this child has here

Other
Please elaborate on your bleeding disorder diagnosis. Include severity, type, and any other notes on your bleeding disorder diagnosis here
Example: Severe Hemophilia A with history of inhibitors
Please select this child's HTC or primary hematologist.

Other
Primary Hematologist Phone Number
Format: (000) 000-0000.
Primary Hematologist Address

Street Address

Street Address Line 2

CityState

Zip Code
Is this child prescribed medication for their bleeding disorder?
Does this child take this medication regularly (prophylaxis) or on-demand?

Other
Will you be bringing this child's bleeding disorders medications with you to camp?
Please list the medication, dosage, AND frequency for all medications taken for this child's bleeding disorder/disorders.
Does this child have any adverse reactions to any bleeding disorder medications?
Please explain any adverse reactions to bleeding disorder medications
Does this child use a port, PICC line, butterfly needle or any other type of medical device to administer medications?
Please explain which device/devices this child uses for administration of medications
Examples: butterfly needle, port, PICC line, etc.
Is this child and/or their family independent with infusions?

Other
Does this child self infuse?

Other
Does this child have an inhibitor?
Is this child on Immune Tolerance Therapy
Please note any problem body parts or "target joints" here
By typing your full name here, you authorize this child's bleeding disorder clinic, as listed above, 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.
Type your full name here to mark your signature.
Other Medical Conditions

This section is to reference medical conditions NOT pertaining to a bleeding disorder
Does this child have any medical conditions (bleeding disorder aside) for which they have seen a medical professional? (including mental health, behavioral or learning differences)
Please explain, in detail, these medical conditions.
Will your family be bringing any medications with you to camp to manage these medical conditions
Please list any medications you will be bringing, dosage, and frequency of use.
Are you independent with management of the medical conditions listed above and administration of any medications pertaining to those medical conditions?
Please explain what support you will need to manage this medical condition at camp.
Does this child have a history of major injury, illness or have they had surgery in the past year?
Please explain/list history here.
Does this child struggle with transitions between activities, caregivers, schedules, etc?
Details:
Please also include any helpful tips for getting to know this child including interests, favorites, etc.
Does this child tend to be nervous or shy in new environments?
Details:
Please include any helpful tips for getting to know this child including interests, favorites, etc.
Share anything you would like NEHA's Family Camp Counselors to know about this child. Please include strengths, interests, strategies that help if your child is struggling at camp (i.e. jokes, quiet time, one on one, favorite stuffed animal etc.), and/or anything else you believe could help smooth your child's process of attending camp.
Immunizations

Your application will not be considered for acceptance if we do not receive these documents by the due date.
Is this child up to date on all immunizations?
Please upload documentation of child's immunizations: Alternatively, you may email immunization records to info@newenglandhemophilia.org or fax them to 781-329-5122 by March 31, 2026.

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

Children 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 during activity rotations. Parents are encouraged to allow children to attend this training independently for best results. Children may also use this time to learn more about injecting subcutaneous medications for a bleeding disorder.

This class is also recommended for children who are already able to self-infuse, as it provides an opportunity to practice their skills and support peers who may be having difficulty. Any child who is able to successfully access a vein using a butterfly needle and obtain blood return will receive the distinguished recognition of a “Big Stick” award at the end-of-week ceremony.
Child Self Infusion Class
Would you like this child to attend child self infusion class?
Has this child attended this class before?
Does this child have experience administering bleeding disorder medication?
Does this child have experience gathering and setting up medical supplies to treat their bleeding disorder?
Please tell us more about this child's experience with self infusion and why you would like them to participate in child infusion class.
By typing your full name here, you confirm that you understand your child may participate in self infusion class during camp which includes using needles, and/or medical supplies which could cause injury.
Type your full name here to mark your signature.
Insurance
Is this child covered by the same family medical/hospital insurance as the Primary Adult registered with this Family Identifier name?
Is this registrant covered by family medical/hospital insurance
Health Insurance Carrier
Policy Number
Group Number (if applicable)
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.
BEHAVIOR AGREEMENT:
IMMUNIZATIONS ATTESTATION

You can upload documentation of child's immunizations on the "Immunizations" section of this form. Alternatively, you may email immunization records to info@newenglandhemophilia.org or fax them to 781-329-5122.

I attest that this child is up to date on all immunizations and will submit documentation to verify this statement by March 31, 2026.

Your application will not be considered for acceptance if we do not receive these documents by the due date.
IMMUNIZATIONS ATTESTATION
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
By typing your full name here you confirm that all above authorizations listed in this registration have been completed accurately.
Typing your full name here marks your signature.
Should be Empty:

Child: NEHA Family Camp Application Form 2026

Emergency Contact Information

Diet and Activity

Allergies and Medications

Bleeding Disorder Questionnaire

Other Medical Conditions

Immunizations

Child Self Infusion Class

Insurance

Authorizations