Cancer Pathways · 2022 In Person Camp Sparkle Registration

General Information

Camper Name

*

First Name

Last Name

Nickname

Date of Birth

*

(mm/dd/yyyy)

Age

*

Gender

*

Male

Female

Other

Race (optional)

Language at home if other than English (optional)

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

T-shirt size

*

Parent/Legal Guardian Name

*

First Name

Last Name

Email

*

Verify Email

*

Cell Number

*

Work number

Parent/Legal Guardian Name (#2)

First Name

Last Name

Email (#2)

Verify Email

Cell Number (#2)

Work number (#2)

What camp is this camper applying for?

*

Camp Sparkle is Monday-Friday, 9:30am-4pm.

Everett (Legion Hall): Aug. 1st-5th.

Tacoma (STAR Center) Aug. 8th-12th.

Has this camper participated in Camp Sparkle in the past?

*

Yes

No

Which of the following outcomes are most important to you regarding what you hope your child will gain through attending Camp Sparkle? Select 3 that are most important to you.

Develop friendships with other kids who share their experience

Learn healthy coping strategies for dealing with emotions related to cancer

Improved communication skills

Learn more about cancer

Have fun

Other

Cancer Information

How is your child impacted by cancer?

*

Has a loved one in cancer treatment

Has a loved one who is post cancer treatment

Has lost a loved one to cancer

They are a cancer patient themselves

Relationship to the loved one with cancer (if applicable)

Type of cancer

*

Diagnosis month and year

*

Death month and year (if applicable)

Please explain how the camper has been impacted by the diagnosis

*

Emergency Contacts (other than parents)

Emergency Contact #1

*

First Name

Last Name

Phone

*

Relationship to child

*

Emergency Contact #2

*

First Name

Last Name

Phone

*

Relationship to child

*

Health Information

Primary Care Provider

*

Institution/Hospital affiliation

*

Insurance Carrier

*

Policy Number

*

Card holder's Name

*

Does your child have any allergies?

*

Yes

No

Type of allergy and reaction

Will you be providing an EpiPen for your child at camp?

Yes

No

Does your child have any dietary modifications?

*

*Please note, Camp Sparkle can only accommodate certain dietary modifications. If your child’s needs cannot be met, you will be asked to provide a lunch and snack for them.

Yes

No

Please explain any dietary modifications:

Is your child currently taking any medication that would need to be given during camp hours (9am to 4pm)?

*

Yes

No

Please explain any medication that would need to be given at camp:

*include name of medication, dose, frequency, and notes on how to administer

Over the counter medications (OTC)

Please note which over the counter medications are okay to give your child if determined necessary by the Camp Director. All OTC medications will be kids strength and given per directions on the bottle.

Tylenol

Ibuprofen

Benadryl

None

Sunscreen

*

I authorize Camp Sparkle staff and volunteers to apply or assist my child in applying broad-spectrum, water-resistant, SPF 50 or higher that is supplied by Camp Sparkle.

Yes

No

Sunscreen

I will provide sunscreen for my child labeled with my child’s name:

Yes

No

Physical Accommodations

*

Will your child need any physical accommodations at camp?

Yes

No

Physical Accommodations

*please explain if needed

Children With Cancer

Skip this section if your child is not the cancer patient. *Please note: Camp Sparkle does not have any licensed medical or oncology providers on staff.

Is your child currently in treatment?

Yes

No

Has your child been deemed medically stable by their provider to participate in a day camp setting?

*In some cases, we may require a doctor’s note.

Yes

No

Behavioral and Emotional Needs

Will your child have any behavioral needs at camp?

*

Yes

No

If yes, please explain:

Will your child have any emotional needs at camp?

*

Yes

No

If yes, please explain:

Is your child currently being treated for any behavioral or emotional conditions (i.e. ADHD, Anxiety, PTSD, etc.)?

*

Yes

No

If yes, what is the diagnosis and how are they being treated:

Swimming Ability

Camp Sparkle will utilize bodies of water and beaches at the parks we are at without trained lifeguards. Counselors and volunteers are available to provide additional supervision. Close counselor supervision is provided and kids are required to stay at hip height water. Please send your child with any necessary equipment.

My child's swimming ability:

*

Strong swimmer (my child can swim unassisted)

Moderate swimmer (can swim in shallow and deep water while supervised)

Weak swimmer (just learning to swim, should always be supervised and kept in shallow water)

Does not know how to swim and always needs a lifejacket

Please briefly describe your child’s swimming ability and any assistance they may need

*

Pick Up Authorization

The following people are authorized to pick up my child from Camp Sparkle, in addition to the parents and legal guardians listed previously. We require photo ID at the time of pick up. You can make changes to this list at any time by emailing the Camp Director at michelle@cancerpathways.org.

#1 Name

First Name

Last Name

#1 phone number

#1 Relationship to child

#2 Name

First Name

Last Name

#2 phone number

#2 Relationship to child

#3 Name

First Name

Last Name

#3 phone number

#3 Relationship to child

#4 Name

First Name

Last Name

#4 phone number

#4 Relationship to child

CONSENT AGREEMENT, AUTHORIZATION, AND RELEASE

This consent agreement, authorization, and release must be read and signed for the participant to be eligible to attend Camp Sparkle and other Cancer Pathways programs. For participants under age 18, this form must be completed and signed by parent/guardian.

Participation Consent

I give permission for my child to participate in any and all activities of Camp Sparkle, including park activities, beach play, swimming and therapeutic activities. Transportation is not provided by Camp Sparkle or Cancer Pathways.

Release of Liability

Recognizing that Cancer Pathways will do its best to ensure a safe experience, I understand that participation in Camp Sparkle carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. Accidents may occur during my child’s participation in camp activities. Knowing the risks of camp, I agree to assume these risks. By signing below, I release Cancer Pathways, its employees, volunteers, independent contractors, directors and agents from all liability based on any damage, loss or personal injury whether it is the result of ordinary negligence or otherwise, caused to my child or to me from participation in the Camp Sparkle program. Further, I acknowledge that Camp Sparkle accepts no responsibility for the loss, damage or theft of personal property. I understand that my child will be released to no one other than myself and the people I have listed on this application under “pick-up authorization.” Transportation is not provided by Cancer Pathways, employees, volunteers, or affiliates. I understand that upon entering and participating in Camp Sparkle and other activities at Cancer Pathways that there is an inherent risk of exposure to the SARS-COVID 19 virus. Cancer Pathways cannot guarantee that my child or I will be protected from exposure to SARS-COVID 19. By signing, I hereby release Cancer Pathways and staff members fro any liability pertaining to the exposure of the SARS-COVID 19 virus, while attending activities with Cancer Pathways.

Consent for Medical Treatment

I hereby give permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a qualified staff member of Cancer Pathways. In the event I cannot be contacted, I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I further consent to the disclosure of health information and to the medical, surgical and hospital care treatment and procedures (including, but not limited to, administration of necessary anesthetics, tests, x-ray examinations, transfusions, injections, drugs) to be performed for my child by a licensed physician or hospital selected by Camp Sparkle staff when deemed immediately necessary or advisable by the physician to safeguard my child’s health.

Photo and Information Release

I hereby give Cancer Pathways and its employees, representatives, and authorized media organizations permission to print, photograph, and record my child during Camp Sparkle for use in audio, video, film, or any other electronic, digital and printed media in order to promote or market Camp Sparkle. This is with the understanding that neither Cancer Pathways nor its representatives will reproduce said photograph, interview, or likeness for any commercial value or receive monetary gain for use of any reproduction/broadcast of said photograph or likeness. I am also fully aware that I will not receive monetary compensation for my child’s participation. I further release and relieve Cancer Pathways, its Board of Trustees, employees, and other representatives from any liabilities, known or unknown, arising out of the use of this material. The camp respects the privacy of its participants and does not allow unauthorized visitors to photograph the camp or camper.

Confidentiality

Camp Sparkle respects the confidentiality of its campers and volunteers. All information given to Cancer Pathways will be kept private. Cancer Pathways will not sell, rent, or give away any camper or family information.

I have read and understand the above and have completed this form to the best of my ability.

*

Yes

No

Parent Signature (electronic signature)

*

Date

*

(mm/dd/yyyy)

COVID-19 precautions

When dropping of my child I agree to answer COVID-19 screening questions truthfully and accurately, agree to providing a mask for my child and agree to a temperature check using a non-contact forehead thermometer each day. Drop off and pick up will be drive through each day.