Camp Next Level (3/03/23-3/05/23) is a one of a kind, premier transitional camp, fun and intense two night, three day boot camp that will prepare teens ages 15-19 with sickle cell disease transitioning into adult care at Camp For All, located in Burton, TX. This boot camp will provide educational tools for disease management, access to care, clinical trial information, treatment education, career planning, pain management, while promoting a fun and engaged environment.
APPLICATION DUE: Friday, February 24, 2023. DO NOT print this application. This form must be filled out and submitted ONLINE ONLY. If you have any questions, please email: info@sicklecelltx.org or call (512) 458-9767.
Health History/Physical Due by February 24, 2023
Please call your child's doctor or nurse as soon as possible to make an appointment for a physical exam. The information we need must be current. We will request an update of your child's health status from his/her doctor before camp. Please fax your childs physical form to 512-233-5869 or via email at info@sicklecelltx.org.
Items To Upload At The End Of This Application:
1. CURRENT PHOTO: Please upload a current photo of this teenager at the end of the app. 2. MEDICAL INSURANCE CARD: Please upload a copy of this teen's insurance card at the end of the app.
Need Help?
If you have questions about this application, about required paperwork, or need further assistance. Please contact the Sickle Cell Association of Texas Marc Thomas Foundation at 512-458-9767 or send an email to info@sicklecelltx.org.
Time To Fill Out Application:
The application will take 20-25 minutes. Please fill it out ENTIRELY. One application per teenager. If you need a hard copy application, please request one by calling (512) 458-9767.
Registration Fee
Camp Next Level is FREE for teenagers with Sickle Cell Disease! Only a $30 non-refundable application fee must be paid with your Application Form. However, it costs this small agency more than $400 to send one teen to camp. If you are able to pay or partially pay (or ask friends or family) for your teen to attend camp the donation will be tax deductible and greatly appreciated. Please copy and paste this URL (https://www.sicklecelltx.org/give/) into your browser to complete the registration fee or make a donation.
Name of Person Filling Out This Application
*
First Name
Last Name
Relationship to Teenager
*
Mother
Father
Aunt
Uncle
Legal Guardian
Grandmother
Grandfather
Self
Other
Email
*
example@example.com
Camper Information
Teen's Name
*
First Name
Last Name
Nickname (put NA if doesn't apply)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Home Phone Number
-
Area Code
Phone Number
Cell Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
Age at Camp
*
Boy / Girl / Other
*
Boy
Girl
Other
Name of School
*
Last School Grade
*
Teen's T-shirt Size
*
Child's Small
Child's Medium
Adult Small
Adult Medium
Adult Large
Adult X-Large
Parent/Guardian Information
Adult 1
*
First Name
Last Name
Relationship
Email
*
example@example.com
Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Address (if different from camper):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Adult 2
*
First Name
Last Name
Relationship
Email
*
example@example.com
Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Address (if different from camper):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contacts
I authorize the following persons to be contacted and give my permission to turn my teen over to these individuals if for any reason my child has to leave camp and I CANNOT BE REACHED (please do not list yourself).
Contact 1
*
First Name
Last Name
Relationship
Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact 2
*
First Name
Last Name
Relationship
Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Teenager's Physician/Clinic
Contact
*
Physician
Clinic
Phone Number
*
-
Area Code
Phone Number
Teenager's Medical Insurance Information
Name of Medicaid/Private Insurance Company
*
Member/Policy/Group ID Number
*
Camper's Information
Please fill this out to the best of your ability. We want to make sure your teenager has a safe, healthy, and fun time at camp. This information is extremely helpful!
Has Your Teen Ever Attended Camp Next Level?
*
Yes
No
Has Your Teen Ever Been Away From Home For More Than Five Days?
*
Yes
No
How Does Your Teen Function in Large Groups?
Does your Teen Get Along With Others?
When Upset, How Does Your Teen Show Aggression Towards Others?
What Can We Do To Calm Your Child, if He/She Gets Really Upset?
How Does Your Teen Feel About Attending Camp?
*
How Did You Hear About Camp Next Level
*
Sickle Cell Association of Texas
Doctor/Nurse
Friend
School
Other
What Type of Sickle Cell Disease Does Your Teen Have?
*
SS
SC
S Beta-Plus
S Beta-Zero
Other
Does Your Teen Get Nose Bleeds?
*
Yes
No
Does Your Teen Use Oxygen, Breathing Machines, or Any Machinery Regularly?
*
Yes
No
If You Answered Yes To The Above, Please Elaborate Below:
Your Teen's Sleeping Habits: (check all that apply)
*
Average Sleeper
Heavy Sleeper
Light Sleeper
Sleepwalks
Bed Wets
Nightmares
Does Your Teen Have Any of the Following Conditions? (check all that apply)
*
Kidney Issues
Breathing Difficulty
History of Strokes
Immune Issues
Monthly Transfusions
Abnormal TCD
Asthma
2 or More Admissions Per Year
Bed Wetting
Allergy Shots
Pregnancy
ADD or Hyperactivity
Speech Difficulty
Hearing Difficulty
Vision Difficulty
Hormone Issues
Headaches
Skin/Staph Infections
Autism
Depression
Anxiety
Oppos/ODD
Emotional Stress
None
Please Elaborate On Any Selections Above
Please List Any of Your Teen's Allergies: (please elaborate on the reaction to the allergy)
For Girls Only!
Has Your DAUGHTER Started Her Period?
Yes
No
If Yes, Will She Start Her Period At Camp?
Yes
No
Does Your DAUGHTER Have Menstrual Cramps?
Yes
No
If Yes, Does She Take Any Medication?
Yes
No
Please List the Medications Below: (if applies)
Share Your Teen:
Please share this teen's history or story so we can understand how to give him or her an even MORE amazing week at camp!
Please Share Strengths and Positive Things About Your Teen. Please Write as Much as You'd Like!
*
Please Share Your Teen's Interests:
*
Please Share A Brief Description of Your Teen's Personality: (outgoing, shy, easily frustrated)
*
Does Your Teen Get Along With Others?
*
Very Well
Fairly Well
With Difficulty
When Upset, How Does Your Teen Show Aggression Towards Others?
Is Your Teen Emotionally Sensitive?
*
Yes
Somewhat
No
In What Situations Does Your Teen Feel Least Comfortable?
*
Please Share Your Teen's Fears or Unusual Behaviors (if any):
Does Your Teen Tend To: (check all that apply)
*
Wander
Daydream
Use Foul Language
Runaway
None
What Kinds of Challenges (If Any) May Your Teen's Camp Counselor Encounter From Your Child?
*
Any Recent Changes In Your Family Or Living Arrangements That We Should Be Aware Of?
*
Any Additional Information You'd Like Us To Know About Your Teen?
Zero Tolerance Policy
The Sickle Cell Association of Texas Marc Thomas Foundation Has A Firm Zero Tolerance Policy. If Any Violations Are Made You Must Pick Up Your Teen From Camp. Please indicate you understand this statement by selecting "yes, I agree" below.
*
Yes, I agree
Medication Release
Over the Counter Medication: The following are medications we keep on hand at camp. Please select which medications you are comfortable with us giving your child. All medications are given according to instructions found on the medication and per Medical Staff Protocol.
*
Acetaminophen (Tylenol)
Antihistamine/Allergy Medicine
Aloe Vera Gel/Lotion
Ibuprofen (Advil, Motrin)
Robitussin or Equivalent
Calamine Lotion
Sudafed PE
Robitussin DM or Equivalent
Antibiotic Cream
Benadryl Cream
Tums/Antacids
Swimmer's Ear Drops
Sore Throat Spray
Laxatives for Constipation
Eye Drops (Visine or Equivalent)
Heating Pads
List ALL prescription medications and over the counter medications taken REGULARLY by your teen:
Name of Medicine
Frequency (per day)
Bring to Camp?
Times Given (morning, afternoon, night)
Dose (tablets, spoonfuls, TBS, TSP)
Medicine 1
Medicine 2
Medicine 3
Medicine 4
Medicine 5
Medicine 6
Medicine 7
Medicine 8
Medicine 9
Medicine 10
I Agree the Information Listed Above is Correct:
*
First Name
Last Name
How Would You Like to Receive the Camp Liability Forms? They Are Available to Download Below. https://www.waiverfile.com/b/CampForAll/Waiver.aspx?id=db8e061c-6a62-424c-8881-7bb4e5a238c8
*
I will download a copy
Please email me a copy
Please mail me a copy
Please Download and Complete the Following Forms:
Release, Waivers, & Zero Tolerance Policy
Physician History & Physical Exam Form - Please Have Your Doctor/Nurse Complete and Fax Back to us. Our main fax number is (512) 233-5869.
Please Upload the Following Items:
If you cannot complete these forms at this time, please continue on to submit this application. Please note, in order for your teen to attend camp, we will need a picture of your teen, a copy of your insurance card, and a COMPLETED Release Waivers & Zero Policy Tolerance Form. Please send us any forms you cannot complete at this time as soon as possible to info@sicklecelltx.org.
Teen's Picture
Browse Files
Cancel
of
Copy of Insurance Card
Browse Files
Cancel
of
Release, Waivers, & Zero Tolerance Policy
Browse Files
Cancel
of
Have Your Doctor/Nurse Fax Over the Following:
A COMPLETED Physician History & Physical Exam Form. Our Austin (main) fax number is (512) 233-5869 and our Houston fax number is (713) 538-8850. Please feel free to fax to either location.
Application Checklist:
Picture
Copy of Insurance Card
Registration Fee or Donation
Release, Waivers & Zero Policy Tolerance Form
Physician History & Exam Form (Have your doctor/nurse fax this to us)
Camp For All Waiver Forms
Please Click the Submit Button Below Upon Completion of the Application:
*
Please note, applications will be reviewed upon receipt. We will contact you to let you know if you/your teen is selected to attend Camp Next Level.
Do you have the ability to pay the registration fee?
Yes
No
My Products
prev
next
( X )
Registraion Fee
$
30.00
Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: