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Family Getaway Application
Qualifying Criteria
• Must have a child under 18 with a chronic illness or physical challenge who is currently being served by a Camp John Marc partner hospital or group. • Cystitis fibrosis patient served in the Dallas/Ft. Worth area under 18.
By checking this box, I agree that I have read and meet the above criteria.
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Yes
Contact Information
Family Name
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Parent #1
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First Name
Last Name
Parent #2
First Name
Last Name
Phone
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Email
*
Verify Email
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Family Getaway Weekends are for family members who currently live in the same household and grandparents. The child with the qualifying medical condition must attend.
Number of Family Members Attending the Getway
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Names of Family Members Attending:
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Name of Child with a qualifying medical condition
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First Name
Last Name
Qualifying Medical Condition
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Age of Child with qualifying medical condition
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Partnering Hospital/Doctor:
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select one
Cook Children's
Children's Health
TSRHC
Other: please specify below
Other:
Who referred you to Camp (Child Life Specialist, Nurse, etc?)
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Have you attended a Getaway before? If so, how many times?
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Are you eligible to attend a Family Camp hosted by one of our partnering organizations at Camp John Marc?
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Yes
No
If so, please list the camp name(s) and dates you have attended or plan to attend.
(mm/dd/yyyy)
Camp Name:
Before the start of the Family Getaway season, applications will be reviewed and priority will be given to families with the greatest need. Are there any current factors that should be considered when your application is review?
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Any information would be helpful to help us prioritize.
Preferred Weekend Getaway Date
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Please select your 1st choice for attending a getaway.
select one
December 13-15, 2019
February 7-9, 2020
February 14-16, 2020
February 21-23, 2020
Secondary Weekend Getaway Date
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Please select your 2nd choice for attending a getaway.
select one
December 13-15, 2019
February 7-9, 2020
February 14-16, 2020
February 21-23, 2020
Alternate Weekend Getaway Date
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Please select your 3rd choice for attending a getaway.
select one
December 13-15, 2019
February 7-9, 2020
February 14-16, 2020
February 21-23, 2020
Parent / Guardian Electronic Signature
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Date
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(mm/dd/yyyy)