Camp@HHome: Winter 2021

1
Camper Name* This field is required.
First Name
Last Name
2
Camper DOB* This field is required.
Date
Year
Month
Day
3
Gender* This field is required.
Male
Female
4
Camper Address* This field is required.Please provide best address for camper to receive mail from camp.
Street Address
Apt., PO Box
City
State
Zip Code
United States
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Cabin ChatsJoin us for an hour on Wednesday evenings. Cabin Chats give an opportunity for campers (ages 6-21 years old) to share about their day and answer fun questions!
YESNO
6
Parent/Caregiver ChatsJoin us for an hour (once a month) on Wednesday evenings. Parent/Caregiver Chats give an opportunity to share and connect with other adults in similar situations.
YESNO
7
Virtual Camp DaysJoins us for a few hours on a Saturday. Camp Days give an opportunity for campers (ages 6-21 years old) to experience fun, themed camp activities at home.
YESNO
8
Do you think your camper will be able to successfully navigate Zoom in order to engage in virtual programming?
Yes
No
9
What accommodations would your camper need to be successful in virtual programming?
Closed captioning
Language support
Visual aids
Prompts and breaks
None needed
10
Has camper previously attended a Double H (in-person or virtual) program?
YESNO
11
Camper Primary Medical Diagnosis* This field is required.If applicable, please list secondary or multiple diagnoses
Huge
Large
Normal
Small
Ok
Ok
12
Parent/Guardian Name
First Name
Last Name
13
Parent/Guardian EmailPlease provide the best e-mail address to receive communications from camp this winter.
example@example.com
14
Parent/Guardian Phone NumberPlease provide the best phone number to reach you.
Area Code
Phone Number
15
Online Safety & Privacy PolicyPlease read, signature will be required!
16
I have read and understand Double H Ranch’s Online Safety and Privacy Policy, and I understand the requirements and expectations of me as a camper family.Please sign
17
Camper Photo Permission?* This field is required.I GIVE the Double H Ranch, SeriousFun Children's Network, Inc., their respective affiliates and the parties permitted by them (collectively, the "Recipients") PERMISSION to photograph and/or videotape my child, and to use my child's name, likeness, image, and/or video in promotional materials, including fundraising, marketing, and educational materials. I understand that my child's name, likeness, image, and/or video may be used to promote public understanding and support of programs for children with critical illnesses, and that the materials containing my child's name, likeness, image, and/or video may be used in the current year and/or in future years. This consent may be revoked in writing at any time, except to the extent that the Double H Ranch has already relied upon it in making use of my child's name, likeness, image, and/or video. I understand that this consent is not a condition of participation in the program.
YESNO
Should be Empty: