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2020 Camp Sparkle Camper Application
General Information
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First Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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Last Name
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Cancer Information
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Emergency Contacts (other than parents)
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Health Information
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*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.

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*include name of medication, dose, frequency, and notes on how to administer
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.
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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.
I will provide sunscreen for my child labeled with my child’s name:
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Will your child need any physical accommodations at camp?

*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.
*In some cases, we may require a doctor’s note.
Behavioral and Emotional Needs
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Swimming Ability
Camp Sparkle will always utilize swimming pools with trained lifeguards. Counselors and volunteers are available to provide additional supervision. Some camp locations include a field trip to local beaches that are not monitored by lifeguards. Close counselor supervision is provided and kids are required to stay at hip height water. Please send your child with any necessary equipment on those days.
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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 maddie@cancerpathways.org.

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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 field trips, swimming, therapeutic activities, and to be transported by Camp Sparkle as authorized by 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.”
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.
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