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Parent Information

First Name*

Last Name*

Email Address*

Relationship*

Cell Phone

Work Phone

Second Parent Information

First Name

Last Name

Email Address

Relationship

Cell Phone

Work Phone

Camper Information

First Name*

Last Name*

Gender*

Date of birth*

Email Address

Diagnosis*

Treatment Status* OnOff

If off, since when?

If no siblings, leave blank, and continue to Home Address.

Siblings

First Name

Last Name

Date of birth

Additional Sibling 02

First Name

Last Name

Date of birth

Additional Sibling 03

First Name

Last Name

Date of birth

Additional Sibling 04

First Name

Last Name

Date of birth



More Siblings? Please let us know in the Comments box at the bottom.

Home Address

Address*

City*

State*

Zip*

International Region

Home Phone*

Additional Information

Which camp are you interested in applying for?* Fantastic Winter Weekend (13- to 25-year-old cancer patients)Ski Family Weekend (camp-eligible families*)BRASS Weekend (7- to 16-year-old siblings of cancer patients)Tidewater Family Weekend (camp-eligible families*)Spring Family Weekend (camp-eligible families*)Young Adults Weekend, or YAC (18- to 25-year-old cancer patients)Reunion Family Weekend (current and past campers and immediate families)Fantastic Friends Weekend (13- to 17-year-old cancer patients and best friend)BRASS Camp (7- to 16-year-old siblings of cancer patients)Camp Fantastic (7- to 17-year-old patients treated in past three years for cancer)Octoberfest Weekend (camp-eligible families*)Parents’ Getaway Weekend (camp-eligible parents and bereaved parents)

*Camp-eligible families are those with 0- to 17-year-old children within 3 years of cancer treatment (or within 5 years of a bone marrow transplant)

How did you hear about us?*

Who did you hear about us from?

Comments/Questions

NIH Life with Cancer KOA Care Camps Children's Oncology Camping Association
Childhood Cancer Community Consortium Youth Development Center NOVA 4H Amazon Smile