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 9 of 18

Camper Name: _________________

Camp Sunrise Camper Application

Page 10 of 18

.

Camper Name: _________________

Camp Sunrise Camper Application

Page 11 of 18

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 oklein2@jhmi.edu

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: ____________________________________________________________________________