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SIGN UP FOR OUR FAMILY CAMPFIRE!
Your Name
*
First Name
Last Name
Email address:
*
example@example.com
Are you a pediatric cancer family or a volunteer/supporter?
*
Pediatric cancer family
Volunteer/Supporter
ELIGIBILITY
Has anyone in your family participated in a Camp Casco program before?
*
Yes
No
WELCOME BACK!
WE'RE SO HAPPY YOU'RE HERE!
How did you hear about this event?
*
Please share a little bit about your family's experience with childhood cancer.
*
Please provide the name and contact information of a medical professional familiar with your family's childhood cancer experience to help us confirm your eligibility for our programs.
By providing this information, you give Camp Casco permission to contact this individual to confirm your family's eligibility for this free program.
Name of Medical Professional
*
Name of Hospital / Clinic
*
Hospital / Clinic Phone Number
*
Name of child who was diagnosed with cancer in your family
*
Date of birth for child who was diagnosed with cancer in your family
*
-
Month
-
Day
Year
Date Picker Icon
Cancer diagnosis
*
Phase of Treatment
*
Please Select
Active Maintenance
Remission
Relapse
N/A
PARTICIPANT INFORMATION
How many adults will be attending?
*
Please Select
1 adult
2 adults
3 adults
4 adults
5 adults
6 adults
7 adults
Name of Adult 1
*
Name of Adult 2
*
Name of Adult 3
*
Name of Adult 4
*
Name of Adult 5
*
Name of Adult 6
*
Name of Adult 7
*
How many children will be attending?
*
Please Select
0 children
1 child
2 children
3 children
4 children
5 children
6 children
7 children
8 children
At least 1 parent or guardian must stay on the premises at all times
Name & Age of Child 1
*
Name & Age of Child 2
*
Name & Age of Child 3
*
Name & Age of Child 4
*
Name & Age of Child 5
*
Name & Age of Child 6
*
Name & Age of Child 7
*
Name & Age of Child 8
*
Does anyone attending have dietary restrictions we should be aware of?
*
Please Select
Yes
No
If yes, please describe.
*
Does anyone attending have any health issues or concerns we should be aware of?
*
Please Select
Yes
No
If yes, please describe.
*
Would you like to receive text message reminders about this event?
*
Yes
No
Phone number
*
Please enter the phone number where you would like to receive text notifications. Standard messaging rates apply.
Participation Authorization
Submit
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