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

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The Valerie Fund’s Camp Happy Times LIT Application

2014 Dates: August 18th – 24th Application Deadline: April 15th

Camp Happy Times Leader-in-Training Program Information

Description
The LIT two-year program is for young adults aged 19, 20 & 21 that have or have had cancer.

Mission
Develop life and leadership skills that can be applied to life situations and assist in developing young adults with their transition into the adult community.

Goals


Qualifications

Acceptance Guidelines

Return completed Medical Applications by the deadline to:
Camp Happy Times, 2010 Millburn Ave, Maplewood, NJ 07040

Questions or Emailing your Medical Application?
Email Milliesue@aol.com(Millie) or mruttler@thevaleriefund.org (Matthew). You can also contact any of us via Facebook!

Personal Information

Last Name* A value is required.
First Name* A value is required.
Nick Name
Graduated HS/GED?* A value is required.
Gender* Please make a selection.
Date of Birth* A value is required.
Age* A value is required.
Social Security #* A value is required.
Cancer Diagnosis* A value is required.
Date of Diagnosis* A value is required.
Driver's License or State ID Number* A value is required.
Issuing state for DL or ID* A value is required.
   
Home Phone* A value is required.
Cell Phone* A value is required.
Home Address* A value is required.
Apt. #
City* A value is required.
State* A value is required.
Zip* A value is required.
County* A value is required.
School/Employer* A value is required.
Email Address* A value is required.
Preferred method of contact*
   
T-Shirt Size*
Pant Size*
Name of Treatment Center*
Name of Doctor at Treatment Center* A value is required.
Name of Social Worker* A value is required.
Treatment Center Phone* A value is required.
   
Will you be receiving treatment for cancer at CHT 2014?* Please make a selection.
Will you be taking any medication while at CHT 2014?* Please make a selection.
Download and send in the medical application. click here

The medical application must be printed from this website and brought to your doctor for completion.
Do you need a paper copy of the medical application mailed to your home? Please make a selection.

Parent / Guardian Information

Who do you live with?* Please make a selection.
Mother/Guardian First and Last Name*     A value is required.
Mother/Guardian Home Number* A value 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.
Extension* A value is required.
   
Father/Guardian First and Last Name* A value is required.
Father/Guardian Home Number* A value is required.
Father/Guardian Cell Number* A value is required.
Father/Guardian Email Address* A value is required.
Father/Guardian Work Number* A value is required.
Extension* A value is required.
   
Emergency Contact Person (NOT PARENT/GUARDIAN) First & Last Name:* A value is required.
Relationship to Applicant:* A value is required.
Emergency Contact Home Phone:* A value is required.
Emergency Contact Cell Phone:* A value is required.
Emergency Contact Work Phone:* A value is required.

Insurance (Please mail a copy of the front and back to the TVF office)

Name of Health Insurance Plan* A value is required.
Health Insurance Policy Number* A value is required.
Health Insurance Group Number* A value is required.

Transportation

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:*
Are you willing to be a bus chaperone (supervise the campers on their way to camp)?* Please make a selection.
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:*
Are you willing to be a bus chaperone (supervise the campers on their way home from camp)?* Please make a selection.

Questionnaire

Please answer all of the following questions as completely as possible.

Briefly explain your reason(s) for volunteering to become a Leader-in-Training(LIT) at Camp Happy Times:*
A value is required.
What do you hope to gain from being an LIT at Camp Happy Times?*
A value is required.
Briefly explain what you have to offer Camp Happy Times and how you intend to deal with the transition from Camper to LIT.*
A value is required.
What do you think your biggest challenge would be as an LIT?*
A value is required.
Do you have any experience in working with children?  What qualities, skills, or other attributes do you feel you have that would benefit the campers?  Please explain.*
A value is required.
What are your goals for the next 12 months?  How will being an LIT help you achieve your goals?*
A value is required.
How would your friends, family and co-workers describe you?  How would you describe yourself?*
A value is required.
If returning to the program, do you have any ideas to improve the program?

Agreements and Authorization

I agree to the CHT Code of Conduct* (read) Please make a selection.
I agree to the CHT general agreement* (read) Please make a selection.
I grant permission for Camp Happy Times or The Valerie Fund to use my name and/or image in print, video or film for any advertising or promotion* Please make a selection.