The Valerie Fund's Camp Happy Times

Supporting comprehensive health care services for
Children with Cancer and Blood Disorders

For More Information:
973-761-0422
home | contact us | Since 1976

Last Name*	A value is required.
First Name*	A value is required.
Nick Name
School Grade as of 9/13*	A value is required.
Gender*	Male Female
Date of Birth*	A value is required.
Age*	Camper's age is required
Cancer Diagnosis*	Camper's cancer diagnosis is required.
Date of Diagnosis*	A value is required.
Camper Home Address*	A value is required.
Apartment
City*	Camper's address city name is required.
State*	Camper's address state is required
Zip*	Camper's city zip code is required
Country*	A value is required.
Camper Email Address*	A value is required.
Camper T-Shirt Size*
Camper's T-Shirt size is required.
Name of Treatment Center: (Select One)*
You must select a treatment center.
Name of Doctor at Treatment Center
Name of Social Worker
Treatment Center's Phone Number
Treatment Center's Fax Number
Will your child be receiving treatment for cancer while at camp?*	Yes No
Will your child be taking other medication while at camp?*	Yes No

Who does the camper live with or has primary custody? *	You must select a primary custody
Mother/Guardian First and Last Name*	Mother/Guardian first and last name is required.
Mother/Guardian Home Number*	Mother/Guardian home phone number is required.
Mother/Guardian Cell Number*	A value is required.
Mother/Guardian Email Address*	A value is required.
Mother/Guardian Work Number*	A value is required.
Mother/Guardian Work Extension

Father/Guardian First and Last Name
Father/Guardian Home Number
Father/Guardian Cell Number
Father/Guardian Email Address
Father/Guardian Work Number
Father/Guardian Work Extension

Emergency Contact Person (First & Last Name) (not the Mother/Father/Guardian)*	A value is required.
Relationship to Emergency Contact*	A value is required.
Emergency Contact Home Number *	A value is required.
Emergency Contact Cell Number *	A value is required.
Emergency Contact Work Number *	A value is required.

How will you ARRIVE at Camp Happy Times 2014?
If you will be arriving by a bus provided by CHT, please indicate the pickup location:
How will you DEPART from Camp Happy Times 2014?
If you will be departing by a bus provided by CHT, please indicate the location you want to return to:

Describe your child’s personality:
Has your child been classified as having a learning disability?	Yes No
Has your child been classified as having a behavioral problem?	Yes No
Does your child need to be reminded of instructions?	Yes No
Does your child have difficulty making friends?	Yes No
Does your child need encouragement?	Yes No
Is your child currently under the care of a mental health provider?	Yes No
If you answered “Yes” to any of the above please provide additional information:

The Valerie Fund's Camp Happy Times Camper Application

How many years has your child attended Camp Happy Times?
What language(s) does your child speak?
Has your child slept away from home other then a hospital stay?	Yes No
Does your child need a night light to sleep?	Yes No
Does your child have any special nighttime routines?	Yes No
If yes, please explain
Does your child have specific fears such as water, darkness, etc?	Yes No
If yes, please explain
Does your child sometimes wet the bed?	Yes No
If yes, any special instructions?
Does your child need assistance getting dressed?	Yes No
Does your child need assistance swimming?	Yes No
Does your child need assistance with the toilet or shower?	Yes No

When was your child first diagnosed?
If your child has ever relapsed, when?
Has your child ever had a port or broviac?	Yes No
If yes, which one?	Port Broviac
Will it be at Camp?	Yes No
Does your child have seizures?	Yes No
Does your child wear a wig?	Yes No
Does your child wear a prothesis?	Yes No
Does your child have food restrictions?	Yes No
Does your child have hair or skin issues?	Yes No
Does your child have difficulty walking?	Yes No
If you answered “Yes” to any of the above please provide additional information:
Our Camp Happy Times counselors are committed to the health and safety of your child during the week at camp. If there is any additional information about your child that would assist us in understanding him/her, please provide us that information.

I agree to the Camper Code of Conduct* (read)	You must agree to the camper code of conduct.
I agree to the Camper General Consent* (read)	You must agree to the camper general consent.
I agree to the Camper Off Site Trip* (read)	You must agree to the camper off site trip
I understand and agree that Camp Happy Times, The Valerie Fund and all of their agents, representatives and employees (paid or volunteer) shall have permission to use my child’s name and/or image in print, video or film for any advertising or promotion.
Please check here if you need a paper copy of the medical application mailed to your home address listed above

Name of Health Insurance Plan
Group Number
Policy Number