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Camp Sunrise Camper Application Sunday, July 30
th - Saturday, August 5
th
Applications Due By Friday, July 7, 2017
Mail Completed Application To:
Jennifer Seiler
P.O. Box 50
Riderwood Post Office
Riderwood, MD 21139
General Information (please print)
Child’s Name: _______________________________________________________ Male ______ Female ______
Address: ___________________________________________________________________________________
City: _________________________________________________ State: ______________ Zip: ______________
Date of Birth: ______/________/_______ Age: __________ Home phone #: (_____) _______________ Cell phone #: (_____)_________________ E-mail address: _________________________________________________________ Grade in school: _________ Child Lives With:___________________________________________________ T-shirt size: child x-small (4-6) child small (6-8) child medium (10-12) child large (14-16)
adult small (34-36) adult medium (38-40) adult large (42-44) adult x-large (46-48) adult xx-large (50-52)
Parent / Guardian name: _______________________________________________________________________
E-mail address: ______________________________________________________________________________
Home phone #: (____) _____________________________ Work phone #: (____)_________________________
Cell phone #: (____) _______________________________ Pager #: (____) _____________________________
Parent / Guardian name: _______________________________________________________________________
E-mail address: ______________________________________________________________________________
Home phone #: (____) _____________________________ Work phone #: (____) ________________________
Cell phone #: (____) _______________________________ Pager #: (____) _____________________________ Persons to contact in case of an emergency if parent/guardian cannot be reached:
Name #1: _________________________ Relationship to child: _________________
Home Phone: (____) ________________ Work Phone: (____) __________________
Pager: (____) ______________________ Cell Phone: (____) __________________
Name #2: ________________________ Relationship to child: __________________
Home Phone: (____) _______________ Work Phone: (____) ___________________
Pager: (____) ______________________ Cell Phone: (____) ____________________
Your child’s medical team:
Primary Care Physician or Pediatrician Name: ___________________________ Phone: ___________________
Oncologist Name: _________________________________________________ Phone: ___________________
Hospital Name: _________________________________ Phone: __________________ Fax: _______________
Primary Nurse Name: ___________________________________ Social Worker Name: ___________________
Camper Name: _________________
Camp Sunrise Camper Application
Page 2 of 18
To Be Completed By Camper What do your friends call you? (Nickname) _____________________________________________
What grade will you be in next year? ___________________________________________________
What are your favorite subjects in school? _______________________________________________
What do you like to do outside of school? _______________________________________________
What are your favorite sports? ________________________________________________________
Do you like crafts? Yes No If yes, what are your favorite crafts? _______________________
Do you know how to swim? Yes No Do you like to dance? Yes No
What is your favorite kind of music? ____________________________________________________
Do you play an instrument? Yes No What? _____________________________________
Do you have a special talent? Yes No What? _____________________________________
Do you play: Checkers? Scrabble? Cards? Chess? _____
Favorite game(s) to play? ____________________________________________________________
Have you been to Camp Sunrise before? Yes No What would you most like to do at camp?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Have you had other camp experience before? Yes No
If Yes, please tell us a little about the camp:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Camper Name: _________________
Camp Sunrise Camper Application
Page 3 of 18
Do you have any brothers and/or sisters? Yes No
If Yes, please fill out the following information along with indicating if they would be interested in learning about our Sibling Camp, SunSibs (annual camp over Memorial Day Weekend):
Is there anything else you'd like to share with us that we didn't ask?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
First Name Last Name Birthday Gender SunSibs
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Camper Name: _________________
Camp Sunrise Camper Application
Page 4 of 18
To Be Completed By Parent The counselors and staff of Camp Sunrise are committed to making the camp experience the most enjoyable and pleasurable week of the year for your child. Each child comes to camp with different needs, varied expectations and individual behaviors. The following questions about your child’s personality and specific needs will provide the staff, and in particular their cabin counselors, with valuable information that will enable them to give the best care to your child. 1. How Would Your Child React to the Following Situations? a. Sleeping in a cabin with a group of children and adults (of the same gender) they might not know:
b. Acting out a skit in front of a group of people: (outgoing/shy?)
c. Being exposed to a new situation or experience:
d. Something is bothering your child. Will they tell someone or keep it to themselves?
e. Your child gets in a disagreement with another child. How will they react?
2. Personal Care and Appearance
a. Does your child need any assistance showering, brushing teeth or going to the bathroom? b. Any bedwetting problems?
b. What is their general schedule for bathing?
Camper Name: _________________
Camp Sunrise Camper Application
Page 5 of 18
3. Physical Needs or Challenges
a. Does your child need any assistance going from activity to activity? (i.e., wheelchair, crutches, physical challenge)
b. Can your child participate in active sports such as kickball, basketball, soccer, etc.?
c. Does your child tire easily when engaged in a physical activity?
d. Is your child particularly sensitive to heat or exposure to sun? e. Does your child have any visual or hearing challenges? (i.e., hearing aids, glasses) 4. Food and Eating
a. Is your child on a special diet?
b. Are there any foods your child particularly enjoys, will not eat, or is allergic to? c. Does your child need any assistance with their meals?
Camper Name: _________________
Camp Sunrise Camper Application
Page 6 of 18
5. Please use the space below to tell us anything else about your child’s personality and specific
needs so that we can best care for your child. 6. On the morning of Sunday, July 30th (the first day of camp), I will: _____ Take my child to the Bus Drop off location: Green Spring Hopkins Campus
10755 Falls Rd. Lutherville, MD 21093 (Pavilion 1)
_____ Take my child to Elk’s Camp Barrett: 1001 Chesterfield Rd. Annapolis, MD 21401
Have to get special permission as space is limited, please call to make arrangements
_____ Take my child to Elk’s Camp Barrett because my child is a Day Camper Please note, the last day for Day Campers will be Friday, August 4th
7. On the morning of Saturday, August 5th (the last day of camp), I will: _____ Pick my child up at the Bus Drop off location: Green Spring Hopkins Campus
10755 Falls Rd. Lutherville, MD 21093 (Pavilion 1)
_____ Pick my child up at Elk’s Camp Barrett: 1001 Chesterfield Rd. Annapolis, MD 21401
***Please note Drop-off and Pick-up times will be included in Acceptance Packets which will be e-mailed in July unless an e-mail is not provided or noted a mailed packet is preferred***
Camper Name: _________________
Camp Sunrise Camper Application
Page 7 of 18
Permission to take part in Camp Sunrise Overnight activities: I give permission for my child to take part in all Camp Sunrise activities and, in consideration of the benefits to be derived I expressly waive all claims against Johns Hopkins University, Johns Hopkins Health System Corporation and their affiliates, and Camp Sunrise staff or their representatives on account of any accident, injury and or illness that may occur during the camp period. ________________________________ Signature of Parent/Guardian Consent for Medical Treatment and Emergency Medical Treatment: I hereby authorize the Medical Director of Camp Sunrise or such designee(s) as the Medical Director may appoint, to provide for the giving of medical treatment and emergency medical care or treatment, including but not limited to medicines, immunizations, x-rays, tests, dental and minor surgical treatment, hospitalization, general anesthesia or other medical treatment as may be appropriate while in the care of Camp Sunrise. Notification of the emergency contact will always be attempted prior to providing emergency medical treatment. I understand that information pertaining to me may be shared with/released to appropriate personnel for the purpose of treatment (including, but not limited to camp medical staff and/or insurance companies). I agree to be financially responsible for the cost of all emergency medical care and treatment provided to me. ____________ ___________________________________________ Date Signature of Parent/Guardian Photo/Video Release Permission: I give permission for any photographs and/or videos that may be taken during the camp period and include my child’s likeness to be used in connection with video slide presentations, future program publicity, fund raising, educational activities, or teaching purposes. I also give permission for pictures taken of me to be shared with other program participants (campers and staff). I waive all claims to compensation and rights regarding such use. YES ____ NO____ If NO, can pictures be taken of your child for the Camp Sunrise Year Book? YES ____ NO____
_____________________________________ Signature of Parent/Guardian
Permission to Complete Attitude Surveys and Program Evaluation Surveys: I give permission for my child to anonymously fill out attitude and program evaluation surveys during Camp Sunrise programming. Information from surveys will be used to evaluate the program and for educational or teaching purposes. YES ______ NO______ _____________________________________ Signature of Parent/Guardian Permission to Include Contact Information in Camp Sunrise Participant Directory I give my permission to include my child’s contact information in the Camp Sunrise directory which will be distributed to program participants. YES ______ NO______ _____________________________________ Signature of Parent/Guardian Transportation Permission: I give my permission to allow my child to travel to and from Camp Sunrise (located at Crownsville, MD) by any transportation. I understand that the transportation will be provided by a licensed commercial vendor, and I acknowledge the normal risks associated with such travel. YES ______ NO______ _____________________________________ Signature of Parent/Guardian I give my permission for my child to be transported by ambulance or by a medical staff member to the nearest hospital in case of an emergency. I acknowledge the normal risks associated with such travel YES ______ NO______ _____________________________________
Camper Name: _________________
Camp Sunrise Camper Application
Page 8 of 18
Signature of Parent/Guardian
Medical Emergency Authorization
As the parent/legal guardian of ____________________________________ (please print name of camper), I give full authorization to Johns Hopkins staff or agents to secure medical care or treatment for said youth. This treatment may include assistance from the nearest physician, medical clinic, hospital, trained nurse or EMT in the event of illness or injury that requires immediate attention, as determined by the event staff. In the event that I cannot be contacted, and an emergency has occurred, I give permission to the treating medical institution and/or medical providers to hospitalize and administer the appropriate treatment deemed medically necessary for my child.
Contact in case of emergency: ________________________________________________________________________________________ Name Relationship Phone Number
________________________________________________________________________________________ Name Relationship Phone Number
________________________________________________________________________________________ Name Relationship Phone Number ________________________________________________________________________________________ Camper Name (print) Last First Middle ________________________________________________________________________________________ Parent/Guardian Name (print)
________________________________________________________________________________________ Parent/Guardian Signature Date
Camper Name: _________________
Camp Sunrise Camper Application
Page 12 of 18
General Health History (To Be Completed By Parent)
CANCER HISTORY Type of Cancer Diagnosis: ___________________________________________________________________________ Date of Diagnosis: _________________________________________________________________________________ What years did you receive cancer treatment? ___________________________________________________________ What treatment did you receive? Chemotherapy Radiation Surgery Other If Other, please explain: _____________________________________________________________________________ Are you currently receiving cancer treatment? YES NO If Yes, please list treatments: _________________________________________________________________________ _________________________________________________________________________________________________ Date of last visit to Oncologist: ________________________________________________________________________
IMMUNIZATION HISTORY: (All immunizations must be kept up to date, if your child is medically exempt from
immunizations, such as in active therapy, please indicate)
*Please include a copy of immunization history*
DPT SERIES __________ LAST TETANUS BOOSTER __________
POLIO BOOSTER __________ LAST TUBERCULIN (PPD) TEST __________
INFLUENZA __________ MMR (MEASLES, MUMPS, RUBELLA) __________
VARICELLA __________
ANY RECENT OR CURRENT INFECTIONS OR COMMUNICABLE DISEASE EXPOSURE?
(PLEASE EXPLAIN): _______________________________________________________________________________
TREATMENT RECEIVED: ___________________________________________________________________________
ALLERGIES:
MEDICATIONS YES NO FOODS YES NO
ENVIRONMENTAL YES NO INSECT STINGS YES NO
OTHER YES NO
If yes or other, please list: ___________________________________________________________________________
_________________________________________________________________________________________________
MEDICATIONS:
Camper Name: _________________
Camp Sunrise Camper Application
Page 13 of 18
MEDICATIONS MUST BE BROUGHT IN ORIGINAL PHARMACY CONTAINERS ***PLEASE BE SURE TO BRING ENOUGH MEDICATION TO GET YOUR CHILD THROUGH THE
ENTIRE WEEK INCLUDING PRN (AS NEEDED) MEDICATIONS AS WELL***
Please print out an up to date list and bring with your child’s medications on the day of camp. Please list heparin flush as
a medication below if your child has a central line. We will supply the heparin flushes.
DRUG DOSE/TIME DAYS OF WEEK
Camper Name: _________________
Camp Sunrise Camper Application
Page 14 of 18
SECONDARY MEDICAL CONDITIONS: Indicate with a check (X) any of the following conditions exhibited by your child.
Please provide detailed information about his/her limitations. Do not hesitate to use an additional sheet to provide more
information which would help us better understand your child.
VISUAL IMPAIRMENTS: _____________________________________________________________________
HEARING IMPAIRMENTS: ___________________________________________________________________
SEIZURES: _______________________________________________________________________________
LEARNING DISABILITIES: ____________________________________________________________________
COGNITIVELY (ACADEMICALLY) FUNCTIONS BELOW AGE LEVEL: _________________________________
FAINTING SPELLS: _________________________________________________________________________
ASTHMA: _________________________________________________________________________________
DIABETES: ________________________________________________________________________________
FREQUENT EAR INFECTIONS: ________________________________________________________________
HEART DEFECT/DISEASE: ___________________________________________________________________
BEDWETTING: _____________________________________________________________________________
PROSTHESIS: _____________________________________________________________________________
BLEEDING/CLOTTING DISORDERS: ___________________________________________________________
CONVULSIONS: ____________________________________________________________________________
SLEEPWALKING: ___________________________________________________________________________
DEPRESSION/ANXIETY: _____________________________________________________________________
OTHER: ___________________________________________________________________________________
SPECIAL DEVICES:
HICKMAN G-TUBE PICC
PORT OTHER: _______________________________________________
CARE (FLUSHES/DRESSING): _________________________________________________________________
COMMENTS:________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Camper Name: _________________
Camp Sunrise Camper Application
Page 15 of 18
RESTRICTIONS:
1. DIET: _______________________________________________________________________________
2. SWIMMING/DIVING: ___________________________________________________________________
3. ACTIVITY LEVEL: _____________________________________________________________________
4. OTHER: _____________________________________________________________________________
SPECIAL ACTIVITIES-OF-DAILY-LIVING NEEDS: (Outline any assistance needed by your child)
DRESSING: __________________________________________________________________________
EATING: _____________________________________________________________________________
BATHROOMING: ______________________________________________________________________
WALKING FROM PLACE TO PLACE: _____________________________________________________
NEEDS WHEELCHAIR ASSISTANCE (DESCRIBE):___________________________________________
Personality Issues/Fears/Parent Concerns: ________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Anything else you’d like the medical staff to know about your child: _____________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
FOR FEMALE CAMPERS:
HAS CHILD EVER MENSTRUATED? YES NO
IF NOT, HAS SHE BEEN TOLD ABOUT IT? YES NO
IF SO, IS HER MENSTRUAL HISTORY NORMAL? YES NO
ANY SPECIAL CONSIDERATIONS? ______________________________________________________
Camper Name: _________________
Camp Sunrise Camper Application
Page 16 of 18
INSURANCE INFORMATION:
*Please include a copy of your insurance card (front & back)*
If Medicaid, specify number: ______________________________________________ Name of Insurance Company: _____________________________________________ Address: ______________________________________________________________ Phone Number: ( ) _____________________________ Policy Number or CIN: ________________________________ If Group Insurance, specify company of employment: ___________________________ Name of Policy Holder: __________________________________________________ Social Security # of Policy Holder: __________________________________________ Social Security # of child: _________________________________________________
Camper Name: _________________
Camp Sunrise Camper Application
Page 17 of 18
Medical Form (please print)
(To Be Completed By Oncologist -- MD, PA, or Nurse Practitioner)
Please print out the following from EPIC: - Medications and allergies OR “Peds Oncology Snapshot”* - Most recent clinic note, including updated problem list
Oncologic diagnosis and summary (date of diagnosis, treatment, surgeries,
radiation, BMT date/complications, GVHD treatment, etc.) (attach extra pages
as needed):
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Expected status of disease at time of camp: In Treatment In remission, ≤6 months from chemo In remission, >6 months from chemo ≤1 year post-BMT >1 year post-BMT
Central Access: Infusaport Hickman PICC Other _________ None
Any other relevant medical information for camp (i.e. activity restrictions, special nursing needs, NG feeds) (attach extra pages as needed): _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ If the child is >6 months from completing treatment or >1 year post-BMT, skip to the signature section on the next page.
If in treatment, current protocol, and chemo patient will be receiving at camp (including oral chemo): _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Will patient need any blood products at camp? Yes No
If yes, what products, and which day: _____________________________________________________
Will patient need any labs drawn at camp? Yes No
If yes, what labs, and which day: ________________________________________________________
Will patient need any IV medications or other medical interventions at camp? Yes No
If yes, what medications, and which day: __________________________________________________
* Click “Snapshot” on the upper left, then “Medication List” or “Meds & Allergies” or “Peds Oncology Snapshot” at
the top. Select print from the top right-hand corner of the screen. Do not check anything off, then click “Continue”.
Camper Name: _________________
Camp Sunrise Camper Application
Page 18 of 18
Instructions for Medical Interventions at Camp:
For Labs: - Place an order in EPIC for a nursing visit, and write in the comments “Visit is for labs drawn at camp Sunrise, the patient will not be in clinic.” - Place future orders for the labs you need drawn as you normally would. - Fill out paper lab order sheets, and print generic yellow patient labels for the tubes. For IV Chemo: - Order the chemo on a separate BDM order from the rest of their orders, and put a comment in saying “Chemo to be administered at Camp Sunrise.” Include anything else they will need on the orders (antiemetics, fluids, etc.). - Photocopy the order, their consent, and their roadmap. - Print out any recent treatment modification notes relevant to their current doses of oral chemo. For IV medication, blood product transfusion, or any other medical interventions: - Hand-write the order as you normally would, including premedication - Include a copy of any necessary consents (ie blood transfusion consents) For Oral chemo: - Photocopy their consent and their roadmap. - Print out any recent treatment modification notes relevant to their current doses of oral chemo.
Hopkins providers: Put all papers/orders/labels in Orly’s mailbox, or in the designated envelope in the
upper level fellow’s office.
Outside providers: Attach documentation to this form, or
Mail to Orly Klein, Bloomberg Children’s Center, 1800 Orleans St., Room 11379, Baltimore, MD 21287
Fax to 410-955-0028
Email to [email protected]
Provider’s Name and Credentials (Print): _______________________________________________
Provider’s Signature: ________________________________________ Date: ________________
If you are not a Hopkins provider, please provide the following as well:
Address: __________________________________________________________________________ ___________________________________________________________________________________
Phone: ___________________________________ Fax: _______________________________ Email: ____________________________________________________________________________