2022 Day Camp Firefly: Camper Application

2022 Camp Firefly

HASDC's Annual Youth Camp for Children Ages 7-14
Submitting a Camp Firefly application DOES NOT guarantee your camper a spot at day camp. As space is limited, applications will be reviewed by HASDC and acceptance will be dependent on the order the application is received and that all required forms are complete, accurate, and submitted.

Camper Information
Camper's Full Name *

First Name Last Name
Camper is: *

a bleeding disorder patient (includes carriers) an unaffected sibling of a bleeding disorder patient
Date of Birth *

Month Day Year
Age *
Camper's Gender Identity: *

Male Female Non-Binary/Non-Conforming Transgender Other
Camper's Primary Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Is this the camper's first year at an HASDC camp? *

Yes No

Parent/Guardian Information

Provide Contact Information for Camper's Primary Guardian
Parent/Guardian (Primary Contact) *

First Name Last Name
Parent/Guardian Preferred Language *
Primary Contact's Relationship to Camper *

Mother Father Grandparent Relative Other
Primary Contact's Address (if different from Camper's)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Contact's Home Phone Number *
Please enter a valid phone number.
Primary Contact's Email *
example@example.com
Primary Contact's Cell Phone Number *
Please enter a valid phone number.

Emergency Contact Information

Not a parent/primary guardian.
Emergency Contact Name *

First Name Last Name
Relationship to Camper *
Home Phone Number *
Please enter a valid phone number.
Cell Phone Number *
Please enter a valid phone number.
Emergency Contact Primary Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Camp Firefly: Day Camp Options

Please indicate which day(s) your child will be participating in.
Camp Firefly: Day Camp Options *

August 13: San Diego Zoo Safari Park & Tour August 14: Picnic & Water Activities at the Bay (camper's immediate family welcome)
August 14: Additional Attendees (Family Members)

Please list additional family members who will be attending the picnic:

	First Name	Last Name	Age
Attendee 1
Attendee 2
Attendee 3
Attendee 4
Attendee 5

Medical History

Provide camper's medical history.
Bleeding Disorder Diagnosis
Factor Deficiency (choose one): *
Severity:

Camp Consents

To be signed by camper's parent/primary guardian.
Permission to Take Photographs

I hereby give consent for photographs and/or motion pictures of my child to be used for any of the following purposes: HASDC publicity, public service announcements on television or the internet, publicity with supporting agencies, scholarship awards, camp promotion or any other agency-approved and supported activity.
Parent/Primary Guardian Signature *

Clear

Release of Liability

To be signed by camper's parent/primary guardian.
I, First Name Last Name , am the parent/ legal guardian of a camper who will travel to and attend Camp Firefly (hereinafter the Camp), sponsored by the Hemophilia Association of San Diego County. I understand that the activities involved in Camp may pose the risk of harm or injury. On my own behalf, and on behalf of my child or ward, I hereby freely and expressly consent to release, discharge, indemnify and hold harmless the Hemophilia Association of San Diego County, and their respective agents, employees, and representatives from any damage, claims, loss, or injury sustained by me or my child/ward while traveling to or from the Camp, while attending or participating in any activities at Camp, or any other trips or activities sponsored by the Hemophilia Association of San Diego County. This release includes within its scope any damage, loss or injury sustained as a result of any ordinary negligence, whether active or passive on the part of the Hemophilia Association of San Diego County, or any of their respective agents, employees or representatives.

As the parent/guardian of the camper, I hereby give my consent to any medical treatment, including any examination, X-ray, anesthetic, medical or surgical diagnosis or treatment, or hospital care to be rendered to me or my child/ward under the general or special provisions of the Medical Practice Act, or to consent to any dental treatment, including any examination, X-ray, anesthetic, dental or surgical diagnosis or treatment, or hospital care to be rendered to me or my child/ward by a dentist licensed under the provisions of the Dental Practice Act. This authorization shall be effective while I or my child/ward is en-route to or from Camp, or involved or participating in any program or activity of Camp, or under the supervision of any personnel associated with the Camp, regardless of the location where treatment or care is rendered, unless earlier revoked by me in writing and delivered to the Camp Director.

The foregoing release is to be construed in accordance with the laws of the State of California. It is intended to release claims, which are not yet known. Accordingly, I hereby waive, on my own behalf, and on behalf of my child/ward, the provisions of California Civil Code §1542, which provides:

“A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor.”

I have read and understood this Release and Authorization and the information I have given is true and correct.
Parent/Primary Guardian Signature *

Clear

Camp Dragonfly Application Fee

All camper's must pay the $25 application fee.

Camper Application Fee

USD Description

Credit Card

Should be Empty:

2022 Camp Firefly

Camper Information

Parent/Guardian Information

Emergency Contact Information

Camp Firefly: Day Camp Options

August 14: Additional Attendees (Family Members)

Medical History

Bleeding Disorder Diagnosis

Medical Information

Immunizations

Allergies

Psychosocial

Other Medical Conditions

Additional Questions

Camp Consents

Permission to Take Photographs

Release of Liability

Camp Dragonfly Application Fee

Credit Card