2021 Kamper/LIT Hybrid Application

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New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish the form. The account you establish is only for this form.

KAMPER - 5 to 17 yrs of age
LIT (Leader-In-Training) 17 & 18 yr. olds
NOTE: 17yr olds have the option to attend as a kamper or LIT
*

New Kamper

Returning Kamper

New LIT

Returning LIT

KAMPER/LIT PERSONAL INFORMATION

Last Name *

First Name *

Middle

Street Address *

City *

State *

Zip Code *

Name on Tag *

Phone Number *

Kamper/LIT Email Address

Social Security Number

Date of Birth *

Gender *

Kay’s Foundation/Kay’s Kamp does not and shall not discriminate on the basis of race, color, religion, creed, gender, gender expression, gender identity, age, national origin, disability, marital status, sexual orientation, genetic information, pregnancy, or veteran or military status, in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers and vendors, and provision of services.

We are committed to providing an inclusive and welcoming environment for all members including, our staff, volunteers, subcontractors, vendors, and participants. We are committed in all areas to providing an environment that is free from harassment. Harassment of others on the basis of their sex, sexual orientation, age, race, color, national origin, religion, marital or veteran status, citizenship, disability, or other personal characteristics covered by Kay’s Foundation’s non-discrimination policy is strictly prohibited.

Age at Kamp *

Grade in the fall *

Cancer Diagnosis *

Date of Diagnosis *

Treatment *

On Therapy	If on therapy, type of treatment _______________ date of last treatment ________
Off Therapy

Name of treating hospital, clinic or place of treatment *

T-Shirt Size

Siblings and or other children in the home *

Yes

No

Name/Age

PARENT/GUARDIAN INFORMATION

Mom (First Name) *

Last Name *

Address *

Home Number *

Cell Phone/Work Phone *

Email Address * 🛈

Contact by Email

Yes

No

Are you interested in joining a private Kamp Facebook group to see daily photos, videos, and messages of your child throughout the week of Kamp? (If you check "yes" you will be notified at the above email address regarding access) *

Yes

No

Dad (First Name) *

Last Name *

Address *

Home Number *

Cell Phone/Work Phone

Email Address *

Name of individual with legal custody if different from above

Work Phone

Cell Phone

Emergency Contact Name (Must not live at same address) *

Relationship

Home Phone

Work Phone

Cell Phone

Emergency Contact Name (Must not live at same address) *

Relationship

Home Phone

Work Phone

Cell Phone

MEDICAL INSURANCE

Yes

No

Name on Primary Insurance

Insurance Company

Group No.

Member No.

Name on Secondary Insurance

Insurance Company

Group No.

Member No.

KAMPER/LIT INFORMATION

Brief explanation of why Kamper wants to come to Kamp

Has kamper ever been convicted of a crime

Yes

No

NOTE: A prior conviction or accusation is not an automatic bar from attending Kay's Kamp. The type of conviction or accusation will be evaluated by Kay's Kamp administration before any decision is made.

	If "Yes", Explain
No. Convictions	If "Yes", Explain
Offense	If "Yes", Explain
Sentence	If "Yes", Explain
Date	If "Yes", Explain

Does kamper use special equipment?

Yes

No

If "Yes", Type of Equipment

Listing of physical restrictions related to Kamp activities.

Does your child(ren) have any behavioral and/or emotional needs that can help ease adjustment to Kamp? (Please be as detailed as possible.)

Is Kamper able to function at his or her own age level? Please describe.

What types of screens will your child(ren) be using to access virtual programs? Please list below.

Any other kamper your kamper would like to be with?

KAMPER/LIT MEDICAL INFORMATION

Name of Oncologist

City

State

Name of Physician/Pediatrician

City

State

Has your child had a bone marrow/stem cell transplant? *

Yes

No

Does Kamper have a Central Line?

Yes

No

Type and Location

KAMPER/LIT MEDICAL HISTORY

Have you/Do you: (If yes, please explain)

1. Have any recent injury, illness or infectious disease?

No

Yes Yes

2. Have a chronic or recurring illness/injury?

No

Yes Yes

3. Been hospitalized in the past 18 months?

No

Yes Yes

4. Had surgery in the past 18 months?

No

Yes Yes

5. Have headaches or migraines?

No

Yes Yes

6. Had a head injury?

No

Yes Yes

7. Been knocked unconscious?

No

Yes Yes

8. Wear glasses, contacts or protective eyewear?

No

Yes Yes

9. Passed out during or after exercise?

No

Yes Yes

10. Been dizzy during or after exercise?

No

Yes Yes

11. Had seizures?

No

Yes Yes

12. Had chest pain during or after exercise?

No

Yes Yes

13. Had high blood pressure?

No

Yes Yes

14. Been diagnosed with a heart murmur?

No

Yes Yes

15. Had back problems?

No

Yes Yes

16. Had problems with joints (knees, ankles, etc.)?

No

Yes Yes

17. Have any skin problems (itching, hives, rash, acne)?

No

Yes Yes

18. Have diabetes?

No

Yes Yes

19. Have asthma?

No

Yes Yes

20. Had mononucleosis in the past 12 months?

No

Yes Yes

21. Had problems with diarrhea/constipation?

No

Yes Yes

22. Have problems sleep walking?

No

Yes Yes

23. If female, have abnormal menstrual history?

No

Yes Yes

24. Had/have an eating disorder?

No

Yes Yes

25. Have ADD/ADHD?

No

Yes Yes

26. Have developmental delays?

No

Yes Yes

27. Have mental health issues? (depression, anxiety, etc.)

No

Yes Yes

28. Use any tobacco products (including E-cigarettes)? *

No

Yes Yes

ALLERGIES: Please list all known allergies including medications, food, environmental, insect, hay fever, asthma, etc. SYMPTOMS/SIDE EFFECTS: Please list side effects including rash, hives, difficulty breathing, shock, etc.

	Allergy to	Symptoms/Side Effects
Allergy	Allergy to	Symptoms/Side Effects
Allergy	Allergy to	Symptoms/Side Effects
Allergy	Allergy to	Symptoms/Side Effects
Allergy	Allergy to	Symptoms/Side Effects
Allergy	Allergy to	Symptoms/Side Effects

MEDICAL DIAGNOSIS

	Please list any additional medical diagnosis that have been made on your child
Medical Diagnosis	Please list any additional medical diagnosis that have been made on your child
Approx. Date of diagnosis	Please list any additional medical diagnosis that have been made on your child
Any complications/changes	Please list any additional medical diagnosis that have been made on your child
Medical Diagnosis	Please list any additional medical diagnosis that have been made on your child
Approx. Date of diagnosis	Please list any additional medical diagnosis that have been made on your child
Any complications/changes	Please list any additional medical diagnosis that have been made on your child

SURGERY

	Please list any surgical procedures your child may have had during their lifetime.
Surgery	Please list any surgical procedures your child may have had during their lifetime.
Date (most recent first)	Please list any surgical procedures your child may have had during their lifetime.
Complications resulting from surgery	Please list any surgical procedures your child may have had during their lifetime.
Surgery	Please list any surgical procedures your child may have had during their lifetime.
Date	Please list any surgical procedures your child may have had during their lifetime.
Complications resulting from surgery	Please list any surgical procedures your child may have had during their lifetime.

Specialists/Therapists

	Please identify any Specialists and/or Therapists that may be assisting in your child's treatments
Name	Please identify any Specialists and/or Therapists that may be assisting in your child's treatments
Specialty	Please identify any Specialists and/or Therapists that may be assisting in your child's treatments
Specific issues	Please identify any Specialists and/or Therapists that may be assisting in your child's treatments
Date of last appointment	Please identify any Specialists and/or Therapists that may be assisting in your child's treatments
Name	Please identify any Specialists and/or Therapists that may be assisting in your child's treatments
Specialty	Please identify any Specialists and/or Therapists that may be assisting in your child's treatments
Specific issues	Please identify any Specialists and/or Therapists that may be assisting in your child's treatments
Date of last appointment	Please identify any Specialists and/or Therapists that may be assisting in your child's treatments

KAY'S KAMP REQUIRES UPDATED IMMUNIZATIONS FOR EACH KAMPER EACH YEAR!

Has your child had any of the following?

	Approximate Date
Measles	Approximate Date
German Measles	Approximate Date
Mumps	Approximate Date
Chicken Pox	Approximate Date
Shingles	Approximate Date
Whooping Cough	Approximate Date

Please check if

Child NOT Vaccinated due to medical treatment

MEDICAL IMMUNIZATIONS

Please list dates of most recent immunizations

	Date
Tetanus (DTaP, DT, Td, or Tdap)	Date
2020-2021 influenza vaccine	Date
Varicella	Date

COVID-19 Information

This information pertains to the Kamper/LIT and any family member living in the same household. *

	Yes	No	If yes, date	Relationship to Kamper
Diagnosed with COVID-19	Yes	No	If yes, date	Relationship to Kamper
Has Kamper/LIT received the COVID-19 vaccine, dose 1?	Yes	No	If yes, date	Relationship to Kamper
Has Kamper/LIT received the COVID-19 vaccine, dose 2?	Yes	No	If yes, date	Relationship to Kamper

SCREENING AND TESTING FOR COVID-19

*

	Yes	No
Do you agree to have your kamper screened for COVID-19?	Yes	No
Do you agree to have your kamper comply with testing protocols in order to attend in-person kamp activities?	Yes	No

Please upload a complete copy of your child's up-to-date immunizations prior to Kamp (or FAX a copy to (302) 834-0367)

Has or will the kamper/LIT or any member of the immediate family travel outside the United States within 30 days of July 26th, 2021? *

Yes

No

If yes, what country(s)?

Kamper Parent/Guardian Authorization

I acknowledge and accept that my child(ren)/family may be participating in video activities that could include them being seen and/or heard on a webcam over the internet. *

Agree

I acknowledge and accept that Kay's Kamp will be using a third party platform such as Zoom, to facilitate video sessions. I agree that Kay's Kamp and Kay's Foundation assumes no liability for any performance issues with this platform or any other third party software. *

Agree

I will encourage my child(ren) to follow appropriate online conduct as explained to them and written in the Kamper Code of Conduct or risk losing privileges to participate in any kamp activity. *

Agree

I acknowledge and accept that others may see our home environment during any session. *

Agree

I acknowledge and accept that any virtual kamp program session may be recorded. These sessions will be stored securely and remain property of Kay's Kamp. *

Agree

Permission to use child(ren) image: I hereby give permission to Kay's Kamp and its representatives to use my child(ren) image, photograph or video for marketing/fundraising and proprietary purposes. *

Agree

NOTE

ALL KAMPER APPLICANTS

Please complete the Parent/Guardian Certification and Authorization

AT THE BOTTOM OF THIS FORM

Then SUBMIT your application

LIT APPLICANTS

Please complete the LIT portion of this application BELOW,

sign the authorization at the bottom of this form,

Then submit your application

Please be sure to print the PHYSICIAN/PNP RECOMMENDATIONS AND RESTIRCTIONS AT KAMP as that form will need to be completed by your kamper/LIT's Physician or Pediatric Nurse Practitioner and provided to Kay's Kamp prior to the beginning of Kamp. Please click the link on the website application page.

Leaders in Training (LIT) Applicants ONLY - Please complete the following

To be considered for the LIT program, the applicant must complete the application process, have a personal interview with the LIT Director or Kamp Director, have a successful criminal background check (18yrs and older), have successful reference checks and attend staff orientation as scheduled.

Applicants for the Leader-In-Training Program must be 17-18 years of age. They will reside and interact with a group of kampers during the week and be responsible for the health and safety of each assigned kamper in the cabin. They will encourage and motivate kampers to participate in all activities. Responsibilities during the week include:

-Assist counselors to ensure order, safety and discipline among kampers

-Knowing the whereabouts of assigned kampers at all times

-Being a role model for the kampers at all times

-Report any concerns of a health nature immediately to the Lead Counselor

-Report any problems or concerns about the safety to the Lead Counselor

-Actively participate with assigned kampers in all activities, remembering that the kampers' needs come first.

Please use the space provided below to answer questions that relate to your interest in being an LIT.

What do you expect to gain from participating in the LIT program at Kay's Kamp?

How is being an LIT different from being a kamper and how would you adapt to those differences?

What leadership characteristics must an LIT possess and why? Who is one individual (friend, family, political figure, etc.) who you admire as a leader and why?

Please list three (3) people who are not your relatives to serve as references.

Please include one (1) former employer (if you have previous work experience) and two (2) people that can attest to your character and ability to work in different situations.

NOTE: Remember when listing a reference that they need to be readily available for contact by Kay's Kamp staff. If we are unable to reach a reference, you will be required to provide an additional name.

REFERENCE #1 NAME

Relationship

Street Address

City

State

Zip Code

Phone Number

Email Address

REFERENCE #2 NAME

Relationship

Street Address

City

State

Zip Code

Phone Number

Email Address

REFERENCE #3 NAME

Relationship

City

State

Zip Code

Phone Number

Email Address

LIT APPLICANTS ONLY

	BACKGROUND CHECK INFORMATION
Driver's License or State ID Name	BACKGROUND CHECK INFORMATION
Driver's License or State ID Number	BACKGROUND CHECK INFORMATION
License or State ID	BACKGROUND CHECK INFORMATION
Expiration Date	BACKGROUND CHECK INFORMATION

All Kamper and LIT applicants must sign the Parent/guardian

certification and authorization below.

Kamper Parent/Guardian Certification and Authorization

As the responsible parent/guardian of the applicant, I hereby certify that the application information provided on this form is current, true and correct to the best of my knowledge.

I hereby waive, release and discharge any and all claims for damages, death, personal injury or property damage which I may have or which may hereafter accrue to me as a result of my child's participation in Kay's Kamp activities. Your agreement discharges in advance Kay's Kamp and all of its agents, representatives, volunteers and employees from any and all liability, claims, costs, expenses and/or damages (collectively referred to as “liability”) arising out of or connected in any way with my child's participation in the activities of Kamp, even through that liability may arise out of negligence or carelessness on the part of the person or entities mentioned above.

I further understand that serious accidents occasionally occur during Kamp activities, and that participation in Kamp activities occasionally sustain mortal or serious personal injuries and/or property damage as a consequence thereof. Knowing the risks of Kamp activities, nevertheless, I hereby agree to assume those risks and to release and hold harmless all of the persons or entities mentioned above who (through negligence or carelessness) might otherwise be liable to my child or to me (or to my heirs or assigns) for damages.

I further agree to indemnify and hold harmless Kay's Kamp in the event or for any other damages any other person, property damages or entity, other than the undersigned, brings an action for the death or personal injuries of my child, as a result of my child's participation in Kay's Kamp activities.

I understand that Kay's Kamp accepts no responsibility for the loss, damage or theft of my child's property.

I agree that if I should not be readily available during the Kamp week, I will advise and keep the Kamp Administration team informed of where I can be contacted in the event of an emergency.

I understand that Kay's Kamp maintains an accident insurance policy on kampers attending the 2021 summer session and that all claims under this policy must be submitted within 30 days of the occurrence of the accident. This policy is in addition to and not in place of health or accident insurance maintained by you.

I recognize and understand that Kay's Kamp is operated as a charitable organization and that my child and I are receiving all of the benefits of Kay's Kamp with minimal or no cost to us.

I hereby give my permission to the Kay's Kamp medical team to administer basic first aid or emergency care if required. In case of a medical and/or surgical emergency, I authorize Kay's Kamp medical staff to arrange for my child to receive x-rays, anesthetic, medical, dental, surgical diagnosis, treatment, and hospital care which is deemed advisable by and is rendered under the supervision of any physician, dentist, surgeon or nurse practitioner licensed to practice in the State of Delaware. I agree to be responsible for all medical transportation and related charges incurred on behalf of my child. I further agree that no Kay's Kamp employee, agent or volunteer will be responsible for injuries or damages arising from the provisions of such emergency treatment or transportation.

I acknowledge that reporters, photographers and other members of the media may attend Kay's Kamp in order to increase the awareness about Kay's Kamp and its programs. I understand that Kay's Kamp is not responsible for the content of the media coverage and that my child will not be paid for any media work.

I authorize my child to engage in all Kamp Activities, except as noted in writing by me or by the physician or PNP completing the Physician/PNP Recommendations and Restrictions form for my child.

LIT Parent/Guardian Certification and Authorization

As the responsible parent/guardian of the applicant, I hereby certify that the application information provided on this form is current, true and correct to the best of my knowledge.

I hereby waive, release and discharge any and all claims for damages, death, personal injury or property damage which I may have or which may hereafter accrue to me as a result of my child's participation in Kay's Kamp. I agree to discharge, in advance, Kay's Kamp and all of its agents, representatives, volunteers and employees from any and all liability, claims, costs, expenses and/or damages (collectively referred to as “liability”) arising out of or connected in any way with my child's participation in Kay’s Kamp, even though that liability may arise out of negligence or carelessness on the part of the person or entities mentioned above.

I further understand that serious accidents may occasionally occur during Kay’s Kamp activities, and that participants in Kamp activities may occasionally sustain mortal or serious personal injuries and/or property damage as a consequence thereof. Knowing the risks of Kamp activities, nevertheless, I hereby agree to assume those risks and to release and hold harmless all of the persons or entities mentioned above who (through negligence or carelessness) might otherwise be liable to my child or to me (or to my heirs or assigns) for damages.

I further agree to indemnify and hold harmless Kay's Kamp and all of its agents, representatives, volunteers and employees from any actions that persons or entities other than the undersigned may bring for damages, property damage, or for the death or personal injuries of my child, as a result of my child’s participation in Kay’s Kamp.

I understand that Kay's Kamp accepts no responsibility for the loss, damage or theft of my child's property.

I agree that if I should not be readily available during the Kamp week, I will advise and keep the Kamp Administration team informed of where I can be contacted in the event of an emergency.

I understand that Kay's Kamp maintains an accident insurance policy on children (kampers) attending the 2021 summer session and that all claims under this policy must be submitted within 30 days of the occurrence of the accident. This policy is in addition to and not in place of any health or accident insurance maintained by the undersigned as legal parent or guardian.

I recognize and understand that Kay's Kamp is operated as a charitable organization and that my child and I are receiving all of the benefits of Kay's Kamp at minimal or no cost to us.

I hereby give my permission to the Kay's Kamp medical team to administer basic first aid or emergency care if required. In case of a medical and/or surgical emergency, I authorize Kay's Kamp medical staff to arrange for my child to receive x-rays, anesthetic, medical, dental, surgical diagnosis, treatment, and hospital care which is deemed advisable and rendered by any attending licensed physician, dentist, surgeon or nurse practitioner licensed to practice in the State of Delaware. I agree to be responsible for all medical transportation and related charges incurred on behalf of my child. I further agree that no Kay's Kamp employee, agent or volunteer will be responsible for injuries or damages arising from the provisions of such emergency treatment or transportation.

I acknowledge that reporters, photographers and other members of the media may attend Kay's Kamp in order to increase the awareness about Kay's Kamp and its programs. I understand that Kay's Kamp is not responsible for the content of the media coverage and that my child will not be paid for any media interviews.

I authorize my child to engage in all Kay’s Kamp Activities, except as noted in writing by me or by the physician or PNP completing the Physician/PNP Recommendations and Restrictions form for my child.

As this application is for a Leader-In-Training (LIT) position, I authorize Kay's Kamp to obtain information pertaining to any charges my child may have for federal and state law violations. This information will include any charges and convictions involving minors, adults or property and will be gathered from any law enforcement agency or any other state or federal government agency to the full extent permitted by law. I understand that such state and federal background access is for the purpose of considering my application as a Leader-In-Training and that I expressly DO NOT authorize Kay’s Kamp, its' directors, officers, employees or other volunteers to disseminate this information in any way to any other individual, group, agency, organization, or corporation.

BY CHECKING THIS BOX, I CERTIFY THE ABOVE APPLICATION INFORMATION THAT I HAVE PROVIDED IS CURRENT, TRUE AND CORRECT AND I HAVE READ AND AGREE TO THE FORGOING TERMS AND CONDITIONS *

Agree to the terms & conditions

BY CHECKING THIS BOX, I AGREE TO CONTACT MY KAMPER'S/LIT'S PHYSICIAN TO HAVE THE PHYSICIAN/PNP FORM COMPLETED PRIOR TO KAMP. (NO kamper/LIT will be allowed to attend Kay's Kamp without a completed PNP form. It is the resposibility of the parent/guardian to follow up with the physician) *

Agree

NOTE: In the event of any custody issues or concerns, Kay’s Kamp must be informed in writing prior to Kamp. It is our policy that if both parents share joint custody of a kamper, they will be considered to have equal rights unless documentation to the contrary is provided.

Please be sure to print the PHYSICIAN/PNP RECOMMENDATIONS AND RESTIRCTIONS AT KAMP as that form will need to be completed by your kamper/LIT's Physician or Pediatric Nurse Practitioner and provided to Kay's Kamp prior to the beginning of Kamp. Please click the link on the website application page.

*

	PLEASE COMPLETE THE FOLLOWING INFORMATION
PARENT/GUARDIAN NAME	PLEASE COMPLETE THE FOLLOWING INFORMATION
CHILD'S NAME	PLEASE COMPLETE THE FOLLOWING INFORMATION
RELATIONSHIP	PLEASE COMPLETE THE FOLLOWING INFORMATION
DATE	PLEASE COMPLETE THE FOLLOWING INFORMATION