The Valerie Fund's Camp Happy Times

Application for Campers

The Valerie Fund's Camp Happy Times Camper Application

2017 Dates: August 14th-20th
Application Deadline: June 1st, 2017

Camp Happy Times Camper Information - Prospective Camper

Camp Happy Times
2101 Millburn Avenue
Maplewood, NJ 07040
Fax to: 973-761-6792 Attn: Camp Happy Times
Scan and Email to: mruttler@thevaleriefund.org

Questions? email us at mruttler@thevaleriefund.org

Personal and Medical Information

All medical information is maintained under the supervision of the Infirmary Medical Supervisor,
Camp Happy Times, and is protected by Federal Confidentiality Laws.
Please complete ALL current information on this page.

Click here to download and send in the medical application.
The medical application must be printed from this website and brought to your doctor for completion.

Last Name* A value is required.

First Name* A value is required.

Nick Name

School Grade as of 9/17* A value is required.

Gender*
Male Female Please make a selection.

Date of Birth* A value is required.

Age* A value is required.

Cancer Diagnosis* A value is required.

Date of Diagnosis* A value is required.

Home Address* A value is required.

Apartment A value is required.

City* A value is required.

State* A value is required.

Zip* A value is required.

Country* A value is required.

Contact Email Address* A value is required.

Camper Status*

T-Shirt Size* Please select an item.

Name of Treatment Center* Please select an item.

Name of Doctor at Treatment Center* A value is required.

Name of Doctor at Treatment Center

Treatment Center's Phone Number

Treatment Center's Fax Number

Will your child be receiving treatment for cancer while at camp?*
Yes No Please make a selection.

Will you be taking additional medication at CHT 2017?*
Yes No Please make a selection.

Does your child have a latex allergy?*
Yes No

Is your child allergic to peanuts?*
Yes No

Does your child have food allergies?*
Yes No

Parent / Guardian Information

Who do you live with?*
Mother & Father Mother Father Guardian 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

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

Emergency Contact Information

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 Information

*You must include a photocopy of the front and back of the camper’s current
health insurance card*

Name of Health Insurance Plan* A value is required.

Health Insurance Group Number* A value is required.

Health Insurance Policy Number* A value is required.

Tranportation

How will you ARRIVE at Camp Happy Times 2017?

If you will be arriving by a bus provided by CHT, please indicate the pickup location:

How will you DEPART from Camp Happy Times 2017?

If you will be departing by a bus provided by CHT, please indicate the location you want to return to:

Camper Questionnaire

Section 1: (Personality)

Describe your child’s personality:

Describe how your child interacts with peers:

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

I hereby authorize The Valerie Fund Camp Happy Times to contact the mental health providers listed below to discuss my child’s special needs. I grant this authorization knowingly and voluntarily and under the condition the information gathered may only be shared with necessary persons, including camp staff and my child’s counselor*

Section 2: (Camp/Cabin Specific)

How many years has your child attended Camp Happy Times?

Does your child speak English

Does your child speak any other language?

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, please explain

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?
Yes No

Does your child need assistance showering?
Yes No

Section 3: (Medical)

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.

Camper Terms Agreement

Please make a selection. I agree to the Camper Code of Conduct* (read)

Please make a selection. I agree to the Camper Code of Conduct* (read)

Please make a selection. I agree to the Camper Code of Conduct* (read)

Please make a selection. 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 make a selection. To ensure the continued safety of all campers and staff, campers' luggage may be searched for prohibited items, such as cell phones, weapons, medicine, and so forth. All items found inappropriate for camp, will be confiscated and held in the Camp Director's office until the end of the week. Some inappropriate items may require a call home or the dismissal from camp. I understand and agree that may child's luggage can be searched.

Please make a selection. Upon arrival to camp, all campers will be screened for lice by medical personnel. In the camp environment, lice can spread quickly from camper to camper. I understand and consent to my child being screened for lice.

Please check here if you need a paper copy of the medical application mailed to your home address listed above

Digital Signature* You MUST sign and date your application.

Camper's Code of Conduct Form

In a continuing effort to offer campers the best week possible with the most memorable outcomes, rules for camper behavior should be understood and agreed upon by the Camper and Parent/Guardian before attending Camp Happy Times. While situations are not anticipated, this code is simply a way to provide a safeguard for the Camp as well as the participants. Please discuss with your child the following rules and the importance of adhering to them during their attendance at Camp Happy Times (CHT).

The Camper and Parent/Guardian must sign this agreement in order to for the applicant to attend. Campers are expected to abide by the following codes

All medications (including over-the-counter) must be kept in the Infirmary. Parents must clearly mark all medication with the Campers Full Name along with an adequate supply for the duration of Camp. The Infirmary shall dispense the respected medications as prescribed by the Campers Physician.

For personal protection, Campers must abide by the established Safety Rules at each activity. Consumption of or the sale of Tobacco Products, Alcohol or Illegal Substance is not permitted.

Campers are encouraged to eat their meals as well as drink fluids at every meal. Campers must also wear sunscreen, hats and shirts at all times for sun protection.

Campers are to abide by common standards of decency including dress and behavior. Abusive language, arguing or fighting between campers, or with the staff is intolerable. (i.e. fighting, threats, insults, cursing and discrimination)

Campers are responsible for their own personal belongings. Campers shall not bring Money or Valuables, including I-Pods and cell phones to Camp Happy Times. Campers must obtain permission to use other’s personal belongings and be respectful in its use.

Pornographic or Offensive Material is not allowed at CHT. This shall include Music and Magazines. Music brought to CHT shall be decent and not contain any profanity. Items of such nature will be confiscated.

Inappropriate displays of affection (i.e. kissing, cuddling or other sexual innuendo) are not acceptable behavior at Camp Happy Times.

Campers may not posses or use weapons or items that may be used to cause bodily harm to self or another.

Campers, of all ages, are not permitted to leave the presence of their counselors at any time. Campers must remain with their cabins at the assigned activities at all times. In addition, Campers may not enter the cabins of the opposite sex.

Campers are not permitted to make phone calls while at CHT, except in the event of an emergency.

Campers must respect the camp grounds- they may not litter or deface camp property and should actively participate in keeping the camp grounds and their cabins clean.

Consequences
Unacceptable behavior during Camp Happy Times (as defined within this Code or through an administrative review process) may result in the following consequences (not necessarily in this order):

A verbal warning

Temporary suspension from camp activities

Restitution or repayment of damages

Early release from Camp Happy Times. (Parent/Guardian assumes responsibility of arranging transportation home in the event of an Early Dismissal)

Denial of future participation in Camp Happy Times for one or more years

NOTE: Any conduct not specifically covered by this code of conduct, but deemed inappropriate by those responsible for Camp Happy Times will be viewed as a violation and appropriate action will be taken. If an infraction occurs, the Camp Director will provide appropriate communication to parent/guardian.

As a participant at Camp Happy Times, I have read and understood the above “Code of Conduct” and will abide by the expectations described in the Code of Conduct. I understand that if I act inappropriately, I will have to accept responsibility for my actions that may result in the consequences listed above.

As parent/guardian, I have discussed and reviewed the above “Code of Conduct” with my child. I understand that failure to abide by the “Code of Conduct” may result in consequences listed above. In the event of that my child is discharged from Camp Happy Times, I assume the responsibility of transporting my child home on the day of such action.

Camper's General Consent Form

I understand and agree that Camp Happy Times, The Valerie Fund and all of their agents, representatives and employees (paid or volunteer) accept no responsibility for the loss, damage or theft of my child’s property.

Should either parents or guardians, during the 2016 Camp Happy Times Session, leave my/our place of residence; I will advise the Camp Administration where I/We can be contacted in the event of an emergency.

I understand and agree that certain activities at Camp Happy Times have an increased risk of injury. I understand and agree to release, waive, indemnify, defend and hold harmless Camp Happy Times, The Valerie Fund and all of their agents, representatives and employees (paid or volunteer) from any and all injuries, losses, claims, cost, expenses and/or damages.

In the event of a medical or surgical emergency, I hereby authorize the Licensed Medical Staff at Camp Happy Times to render to my child or arrange for my child to receive any and all treatment deemed advisable by them and to be rendered under the supervision of medical personnel. I understand that I am responsible for obtaining insurance authorization or referral if needed for such treatment and any cost incurred for such that any existing insurance may not cover. I also understand that I will be contacted in the event of an emergency.

All information is correct so far as I know and the child/camper herein described has permission to engage in all prescribed camp activities, except as noted by me and the examining physician. By signing below, I hereby understand and agree with all of the terms listed above.

Camper's Off-Site Trip Form

I hereby authorize The Valerie Fund’s Camp Happy Times to take my child to any scheduled off-site trip. This authorization includes all travel to and from, and attendance at an off-site event. Parent grants this authorization knowingly and voluntarily and fully recognizing the potential risks and hazards (to both persons and property) that may be associated with travel to and from, and attendance at an off-site event. In consideration for The Valerie Fund agreeing to take Camper to an off-site event, Parent knowingly and voluntarily releases and discharges The Valerie Fund, its officers, directors, employees, volunteers, trustees, administrators and agents (collectively “Releasees”), from any and all liability, demands, causes of action, legal proceedings, damages (including, but not limited to, damage or injury to persons or property) and claims of every kind, nature and description whatsoever, whether known or unknown, including attorneys’ fees and costs related thereto (collectively “Claims”), which against Releasees, its successors and assigns, Parent, on behalf of Parent’s self, Parent’s spouse, children, guardians, heirs, executors, administrators, predecessors, successors and assigns (“Releasors”) has, had or may have, relating to any off-site trip. Parent further agrees to defend, indemnify and hold the Releasees harmless from and against any and all Claims arising out of or related to the acts or omissions or Camper in connection with travel to and from, and attendance at any off-site trip.

Annual Hope & Healing Campaign

I would like to make a Tribute

Programs and Services

Application for Campers