2026 Adult Counselors (21+) - Camp Hemotion Application

Camp Hemotion 2026 Adult Counselors (Ages 21+)

Welcome back to NorCalBDF's Annual Summer Camp! – Inspiring the Leaders of Tomorrow –
Getting Started & Information
- Please set aside approximately 30 minutes to complete the application.
- Ensure you have all necessary information before beginning your application, including health details and required documents.
- Submitting a Camp Hemotion application does not guarantee a spot at camp.
- Space is limited and NorCalBDF's will review applications in the order they are received.
- Acceptance will depend on availability and whether all required forms are complete, accurate, and submitted on time.
  If you have any questions or need assistance filling out your application, please email outreach@norcalbdf.org for assistance. (Se habla español).
Application Deadline: Sunday, May 24th

Required Camper Form Due: Sunday, May 31st
To submit your Adult Counselor application to Camp Hemotion 2026, these two steps must be completed:
1. Complete and sign this Camp Hemotion application here. This includes:
  - Medications: Provide a complete list of your medications, including (but not limited to) factor, prescription medications, over-the-counter medications, and inhalers.
  - Health Insurance Cards: Provide a photocopy (front and back) of your insurance card(s).
2. Fill out and sign the Camp Oakhurst Medical Release Form.

Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Relationship to Adult Counselor*
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Communication Methods (select all that apply)*

Home PhoneCell Phone
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Emergency Contact's Email*
example@example.com

Insurance Information

Provide Adult Counselor's insurance information
Adult Counselor has insurance*

YesNo (NorCalBDF will contact you privately for follow-up)
Insurance Company*
Name of Policy Holder*
Insurance Company Phone Number*
Please enter a valid phone number.
Policy Number*
Group Number*
CCS Number
MediCal Number
Adult Counselor's Insurance Card: Upload FRONT AND BACK of card(s):*

Please upload the FRONT AND BACK of the requested documents. Multiple files can be uploaded in the box above.
Cancelof

Healthcare Provider Information

Provide Counselor's healthcare provider.
Primary Care Physician
Primary Care Physician's Name*

First NameLast Name
Primary Care Physician's Phone Number*
Please enter a valid phone number.
Date of Last Physical*

MonthDayYear
Date

Hematologist | HTC Provider

Provide hematologist information for counselor diagnosed with a bleeding disorder.
Hemophilia Treatment Center (HTC)
Adult Counselor is seen by a Hematologist*

YesNo
Hemophilia Treatment Center*

Stanford University Medical CenterUCSF Benioff Children's Hospital OaklandUC DavisUC San FranciscoValley Children's HospitalOther
Hematologist's Name*

First NameLast Name
Hematologist Phone Number*
Please enter a valid phone number.
Date of Last HTC Visit

MonthDayYear
Date

Required Adult Counselor Form

Form must be submitted by Sunday, May 31st.
- Camp acceptance is contingent upon the submission of this document.
- An incomplete or unsubmitted form may result in delays or forfeiture of the application.
2026 Oakhurst Health & Release Form

Click the link above to complete and sign yourself.

OR

Click here to DOWNLOAD and complete the form offline.

Email back to outreach@norcalbdf.org with file titled "FirstName-LastName-2026 Oakhurst Health Release Form".
- This liability form is required by our campgrounds host, Camp Oakhurst.

Authorizations and Consent for Treatment

I, the undersigned parent/guardian, give permission for my child to participate in all camp activities designed for his/her age group. I further authorize the Northern California Bleeding Disorders Foundation & Camp Oakhurst as agent for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under general or special supervision of any physician and surgeon licensed under the provisions of the medicine practices act on the medical sta of local hospitals whether such a diagnosis or treatment. is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his/her best judgment may deem advisable. This authorization is given in pursuant to the provisions of Section 25.8 of the Civil Code of California.
Signature*

Powered by Jotform SignClear
MEDICAL RELEASE:This health history is correct so far as I know and this person has the permission of the undersigned to engage in all camp activities except as noted. In the case of illness or injury, Northern California Bleeding Disorders Foundation and Camp Oakhurst has my permission to procure medical treatment for the above named (minor, if applicable). I understand the Northern California Bleeding Disorders Foundation and Camp Oakhurst does not provide medical insurance or reimbursement for medical fees or prescriptions and that I am responsible for any / all such fees and charges arising from illness or injury that may occur.

LIABILITY RELEASE: The undersigned, for himself or herself and on behalf of his or her child(ren) or ward(s) and their personal representatives assigns or heirs, (hereinafter referred to as Releasors,) hereby releases and agrees and covenants not to sue Northern California Bleeding Disorders Foundation and Camp Oakhurst, their owners, directors, stockholders, agents, successors, or any employee, (hereinafter referred to as Releasees,) from any and all liability for loss, damage, injury, death, or any other claim whatever to the person or property of any guest or participant whether caused by negligence of Releasees or any other person or thing while participating in activities sponsored by or associated with Northern California Bleeding Disorders Foundation and Camp Oakhurst The undersigned elects to participate and/or allow his or her child(ren), ward(s) to participate voluntarily and assumes all risk of loss, damage, injury or death, known or unknown, foreseen or unforeseen, that may be sustained.

YOU HAVE THE OPTION NOT TO PARTICIPATE OR ALLOW YOUR CHILD, CHILDREN, WARD OR WARDS NOT TO PARTICIPATE IN ANY ACTIVITY WHERE YOU DO NOT WISH TO WAIVE LIABILITY. IT SHALL BE YOUR RESPONSIBILITY TO INSURE THAT YOUR CHILD, CHILDREN, WARD OR WARDS DO(ES) NOT PARTICIPATE IN THE ACTIVITIES FOR WHICH YOU CHOOSE NOT TO BEAR LIABILITY.

The undersigned has read and voluntarily signs this medical release and waiver of all liability.
Signature*

Powered by Jotform SignClear
Indemnification Authorization:
Media Release: I agree that the Northern California Bleeding Disorders Foundation may use, re-use, publish, or re-publish in whole or in part, individually or in conjunction with others my image or my child’s image in any medium and/or for any purpose whatsoever, including but not limited to illustration, promotion, website, and/or advertising trade. I further release the Northern California Bleeding Disorders Foundation, its Board, its officers and representatives from any and all claims of any nature arising from any medium and/or publication.
Signature*

Powered by Jotform SignClear

Camp Hemotion Admission Portal
Camp Hemotion Cost, Support, and Camp Value

Camp Cost: NorCalBDF offers its flagship program, Camp Hemotion, for FREE to the community. We believe that no child should ever miss out on camp due to financial challenges.

Camp Support: Your Contribution Makes a Difference!

While Camp Hemotion is provided free by NorCalBDF, it costs the chapter $1,650 per person to attend the full week at camp. Your support ensures Camp Hemotion keeps running, improves our programming, and maintains program and medical supplies. The full cost of camp represents more than just a weekend away—it’s an investment in a safe, enriching, and unforgettable experience for our community.

Camp Value: Camp offers tremendous value to a child's growth and the community as a whole. Most campers, staff, and camp alumni agree that Camp Hemotion is an incredible and life-changing experience.

Here are some key values that Camp Hemotion offers:
- Gaining independence by learning how to self treat their bleeding disorder
- Learning more about their (or their sibling's) bleeding disorder(s)
- Experiencing new skills like swimming, archery, rock climbing, hiking, and stage performing (camp skits and talent show)
- Opportunities to play various sports in a safe environment
- Learning more about nature and their environment
- Learning how to socialize and make new lifelong friendships
Your support helps cover essentials like:
- Three nutritious meals a day plus snacks during non-meal hours
- Bus transportation
- Engaging activities led by trained Camp Staff
- Comfortable accommodations in cabins that have heating and AC
- It also provides for professional, trained medical staff who dedicate their time to ensuring every child’s health and safety throughout the weekend. Every dollar you contribute helps create a secure, supportive environment where kids can build confidence, forge lifelong friendships, and experience the magic of camp. Your generosity makes this life-changing experience possible—thank you for investing in their future.
Thank you for being part of the NorCalBDF family. We’re excited to create unforgettable memories with everyone!

Warmly,
The NorCalBDF Team

Please choose an option to secure your spot at Camp Hemotion:*

Option 1: Adult Counselor Volunteer Product Image

Option 1: Adult Counselor VolunteerI am volunteering my time and services as an Adult Counselor for Camp Hemotion.

$ Free

Option 2: Camp DonationIn addition to volunteering my time and services, I would like to support Camp Hemotion with a financial donation.

$25.00 Contribution Amount:
Item subtotal:$0.00

Total

$0.00

Payment Methods

Credit Card

ACH Bank Transfer

We sincerely thank you for being a part of our community and for helping keep Camp Hemotion thriving!

We’ll see you at camp!
Should be Empty:

	Medication Name	Dosage Amount	Sat	Sun	Mon	Tue	Wed	Thu	Fri	Sat	As Needed
1
2
3
4
5
6
7
8
9
10

Camp Hemotion 2026 Adult Counselors (Ages 21+)

Getting Started & Information

To submit your Adult Counselor application to Camp Hemotion 2026, these two steps must be completed:

Counselor Information

Emergency Contact Information

Insurance Information

Healthcare Provider Information

General Medical Information

Medical Information

Immunization Records

Bleeding Disorder Information

Hematologist | HTC Provider

Bleeding Disorder Medical History

Required Adult Counselor Form

Camp Hemotion Admission Portal

Camp Hemotion Cost, Support, and Camp Value

Payment Methods