Campers! Apply Here. Play Pause Unmute Mute Camper InformationThis is a cost-free camp for children ages 7-15 who have or have had cancer and one brother or sister. The application requires health history information. All pages must be completed before you can submit the application. All applications must be in by June 2nd, 2023. Campers should not be in active treatment at the time of camp. No IV medications will be given at camp, and campers should not have central lines in place. If there is any questions about this please don't hesitate to reach out to the staff at Camp Courage at campcouragecolorado@gmail.comEmail Address *Please provide the best email address to contact youFirst Name *Last NameAge: *Grade This Fall Semester *Select1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th GradeFreshmenSophomoreJuniorSeniorBirthday *Gender *SelectMaleFemalePrefer not to sayOtherT-Shirt Size *SelectYouth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult XLAdult 2XLOtherHas your child attended Camp Courage before? If yes, how many times? *Sibling InformationEmail AddressPlease provide the best email address to contact youFirst NameLast NameAge:Grade This Fall SemesterSelect1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th GradeFreshmenSophomoreJuniorSeniorBirthdayGenderSelectMaleFemalePrefer not to sayOtherT-Shirt SizeSelectYouth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult XLAdult 2XLOtherHas your child attended Camp Courage before? If yes, how many times?Parent/Guardian #1Name *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweHome Phone *Mobile Phone *Email Address *Employer *Work Phone *Parent/Guardian #2NameStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweHome PhoneMobile PhoneEmail AddressEmployerWork PhoneHousehold InformationFamily Status *SelectMarriedDivorcedSeparatedSingle MotherSingle FatherOtherCustody *SelectMotherFatherJointGrandparent(s)Guardian(s)OtherHow did you hear about us? *SelectDoctorNurseSocial WorkerFriendInternetOtherEmergency Contact #1Additional Emergency Contact Information In an emergency we will always call the parents/guardians first. If we are not able to reach you we need two additional people that can be contacted in case of emergency. Please do not put yourself or your spouse as the emergency contact.First Name *Last NameRelationship *Home PhoneMobile Phone *Emergency Contact #2Additional Emergency Contact Information In an emergency we will always call the parents/guardians first. If we are not able to reach you we need two additional people that can be contacted in case of emergency. Please do not put yourself or your spouse as the emergency contact.First Name *Last NameRelationship *Home PhoneMobile Phone *Medical InformationPlease complete all of this information even if the patient is no longer on treatment.Child's cancer diagnosis *Date of diagnosis *Date(s) of any relapse(s) *Cancer Physician *Cancer treatment facility/facilities *Current stage of treatment *SelectOn treatmentOff treatmentIf off treatment, how long off treatment? *Health History Form: CamperPlease complete the following Health History form as part of your child’s application. It is essential that we have current health information in order to ensure the safety and well-being of campers during their time at Camp Courage.Full Name *Height *Weight *Last Exam Date *Does the camper have any allergies? Please list all and mention if its food, medicine, environmental, or other. *If yes, please provide details abou the camper's anaphylaxis, including the date and description of the reaction. *Does the camper require an EpiPen? *SelectYesNoDoes the camper have any dietary restrictions? We can accommodate camper’s dietary restrictions if we know of them well in advance. If the camper has other dietary restrictions please contact Camp Courage to discuss. *SelectYesNoIf yes, please explain:Medications and Treatments1. We cannot dispense any medication not in a prescription container, so please send original prescription container. Any remaining meds will be returned. 2. Meds are given at breakfast, lunch, dinner, and bed time unless absolutely necessary at other specific times. 3. For antibiotics or other meds taken for a limited time (i.e. days 1-20) please note day started.Will the camper be taking any medications while at camp? Medicine must be brought to camp in its original packaging. *SelectYesNoDrug Name/Strength, Amount and FrequencyMedications and TreatmentsThe following over-the-counter medications may be given to your child as needed, if deemed necessary, by the camp medical personnel. Over-the-counter medications used at Camp Courage include: Acetaminophen (Tylenol),ibuprofen (Advil, Motrin), aspirin, antihistamines (Benadryl, Claritin, Zyrtec, etc.), Pepto-Bismol, hydrocortisone cream, insect repellent, and sunscreen.If the camper cannot take any of these medications, please list them below, along with the reason why the medication cannot be used:Will the camper require any treatments while at camp? *SelectYesNoIf yes, please explain what treatment(s) must be given to the camper, including the frequency and how the medication should be administeredDoes the camper regularly take any medications that will not be taken at camp? *SelectYesNoIf yes, explain what medications the camper takes regularly and why they are taken.Immunization HistoryPlease attach a copy of your child’s immunization record, or list the date of your child’s most recent vaccination below:Immunization RecordChoose FileNo file chosenDelete uploaded fileDiptheria, Pertussis, Tetanus (TdaP or DTdaP)Tetanus booster (dT or TdaP)MMR (Measels, Mumps, Rubella)Polio (IPV/OPV)Haemophilus Influenza B (HIB)PCV (Pneumococcal)Hepatitis AHepatitis BChicken Pox (Varicella)Meningococcal Meningitis (MCV4)If the camper has not been fully immunized or has had any of the above illnesses, please explain. Please include dates and details.Has your child had a TB test?SelectYesNoDate of most recent TB test?What was the result of your child’s most recent TB test?SelectPositiveNegativeIf positive, please explain:Does the camper have ADD/ADHD, developmental delays, autism, Down Syndrome, mental health issues, or behavioral issues? *SelectYesNoIf yes, please explain:If yes, will they be on medication while they are at camp?Will this diagnosis require treatment, restrictions, or accommodations while they are at camp?Does the camper get homesick or have separation issues when away from home? *SelectYesNoIf yes, please explain:Does the camper have depression or an eating disorder? *SelectYesNoIf yes, please explain:Does the camper have asthma, problems breathing, coughing, or lung disease? *SelectYesNoIf yes, please explain:If yes, is the condition mild, moderate, or severe? Is it triggered by anything?If yes, do they carry an inhaler with them?Does the camper have seizures, epilepsy, convulsions, fainting, or blackouts? *SelectYesNoIf yes, please explain:If yes, how frequently and what is the date of the last seizure or episode?If yes, will they be on medication while they are at camp?If yes, what else do we need to know about the seizures or episodes?Does the camper have mobility issues, difficulty walking, braces, etc.? *SelectYesNoIf yes, please explain:Does the camper use a wheelchair, have a prosthesis, or prosthetic joints? *SelectYesNoIf yes, please explain:If they use a wheelchair, what percentage of the time will it be used at camp?Does the camper have a history of concussions or get headaches? *SelectYesNoIf yes, please explain:Does the camper have trouble seeing clearly (uses eyeglasses, contacts, etc.)? *SelectYesNoIf yes, please explain:Does the camper have speech problems? *SelectYesNoIf yes, please explain:Does the camper have hearing or other ear problems? *SelectYesNoIf yes, please explain:Does the camper have a shunt (drains excess fluid from brain) or Ommaya Reservoir? *SelectYesNoIf yes, please explain:Does the camper have neck, chest, or back pain or injury? *SelectYesNoIf yes, please explain:Does the camper have intestinal problems (Crohn’s/Colitis/Constipation/Diarrhea/Ulcer)? *SelectYesNoIf yes, please explain:Does the camper have diabetes, heart disease, or high blood pressure? *SelectYesNoIf yes, please list the diagnosis, date diagnosed, and required care:Does the camper have a skin condition or bleeding disorder? *SelectYesNoIf yes, please explain:Does the camper wet the bed, sleepwalk, have nightmares, or night terrors? *SelectYesNoIf yes, please explain:Does the camper have any restrictions on activity? *SelectYesNoIf yes, please explain what activities must be restricted and any special accommodations that should be made:Will the camper require any special assistance while at camp (getting dressed, showering, bathroom, etc.)? *SelectYesNoIf yes, please explain what assistance will be required:Are there any custody issues we should know about? *SelectYesNoIf yes, please explain. Please be specific:Please inform us of anything you'd like us to know about the camper. This includes any other health conditions, mental or physical, that will require treatment, restrictions, or any other accommodations while your child is at Camp Courage. Please be specific.COVID-19 Vaccination Card. Please upload your campers vaccine cards.Choose FileNo file chosenDelete uploaded fileHealth History Form: SiblingPlease complete the following Health History form as part of your child’s application. It is essential that we have current health information in order to ensure the safety and well-being of campers during their time at Camp Courage.Full NameHeightWeightLast Exam DateDoes the camper have any allergies? Please list all and mention if its food, medicine, environmental, or other.If yes, please provide details abou the camper's anaphylaxis, including the date and description of the reaction.Does the camper require an EpiPen?SelectYesNoDoes the camper have any dietary restrictions? We can accommodate camper’s dietary restrictions if we know of them well in advance. If the camper has other dietary restrictions please contact Camp Courage to discuss.SelectYesNoIf yes, please explain:Medications and Treatments1. We cannot dispense any medication not in a prescription container, so please send original prescription container. Any remaining meds will be returned. 2. Meds are given at breakfast, lunch, dinner, and bed time unless absolutely necessary at other specific times. 3. For antibiotics or other meds taken for a limited time (i.e. days 1-20) please note day started.Will the camper be taking any medications while at camp? Medicine must be brought to camp in its original packaging.SelectYesNoDrug Name/Strength, Amount and FrequencyMedications and TreatmentsThe following over-the-counter medications may be given to your child as needed, if deemed necessary, by the camp medical personnel. Over-the-counter medications used at Camp Courage include: Acetaminophen (Tylenol),ibuprofen (Advil, Motrin), aspirin, antihistamines (Benadryl, Claritin, Zyrtec, etc.), Pepto-Bismol, hydrocortisone cream, insect repellent, and sunscreen.If the camper cannot take any of these medications, please list them below, along with the reason why the medication cannot be used:Will the camper require any treatments while at camp?SelectYesNoIf yes, please explain what treatment(s) must be given to the camper, including the frequency and how the medication should be administeredDoes the camper regularly take any medications that will not be taken at camp?SelectYesNoIf yes, explain what medications the camper takes regularly and why they are taken.Immunization HistoryPlease attach a copy of your child’s immunization record, or list the date of your child’s most recent vaccination below:Immunization RecordChoose FileNo file chosenDelete uploaded fileDiptheria, Pertussis, Tetanus (TdaP or DTdaP)Tetanus booster (dT or TdaP)MMR (Measels, Mumps, Rubella)Polio (IPV/OPV)Haemophilus Influenza B (HIB)PCV (Pneumococcal)Hepatitis AHepatitis BChicken Pox (Varicella)Meningococcal Meningitis (MCV4)If the camper has not been fully immunized or has had any of the above illnesses, please explain. Please include dates and details.Has your child had a TB test?SelectYesNoDate of most recent TB test?What was the result of your child’s most recent TB test?SelectPositiveNegativeIf positive, please explain:Does the camper have ADD/ADHD, developmental delays, autism, Down Syndrome, mental health issues, or behavioral issues?SelectYesNoIf yes, please explain:If yes, will they be on medication while they are at camp?Will this diagnosis require treatment, restrictions, or accommodations while they are at camp?Does the camper get homesick or have separation issues when away from home?SelectYesNoIf yes, please explain:Does the camper have depression or an eating disorder?SelectYesNoIf yes, please explain:Does the camper have asthma, problems breathing, coughing, or lung disease?SelectYesNoIf yes, please explain:If yes, is the condition mild, moderate, or severe? Is it triggered by anything?If yes, do they carry an inhaler with them?Does the camper have seizures, epilepsy, convulsions, fainting, or blackouts?SelectYesNoIf yes, please explain:If yes, how frequently and what is the date of the last seizure or episode?If yes, will they be on medication while they are at camp?If yes, what else do we need to know about the seizures or episodes?Does the camper have mobility issues, difficulty walking, braces, etc.?SelectYesNoIf yes, please explain:Does the camper use a wheelchair, have a prosthesis, or prosthetic joints?SelectYesNoIf yes, please explain:If they use a wheelchair, what percentage of the time will it be used at camp?Does the camper have a history of concussions or get headaches?SelectYesNoIf yes, please explain:Does the camper have trouble seeing clearly (uses eyeglasses, contacts, etc.)?SelectYesNoIf yes, please explain:Does the camper have speech problems?SelectYesNoIf yes, please explain:Does the camper have hearing or other ear problems?SelectYesNoIf yes, please explain:Does the camper have a shunt (drains excess fluid from brain) or Ommaya Reservoir?SelectYesNoIf yes, please explain:Does the camper have neck, chest, or back pain or injury?SelectYesNoIf yes, please explain:Does the camper have intestinal problems (Crohn’s/Colitis/Constipation/Diarrhea/Ulcer)?SelectYesNoIf yes, please explain:Does the camper have diabetes, heart disease, or high blood pressure?SelectYesNoIf yes, please list the diagnosis, date diagnosed, and required care:Does the camper have a skin condition or bleeding disorder?SelectYesNoIf yes, please explain:Does the camper wet the bed, sleepwalk, have nightmares, or night terrors?SelectYesNoIf yes, please explain:Does the camper have any restrictions on activity?SelectYesNoIf yes, please explain what activities must be restricted and any special accommodations that should be made:Will the camper require any special assistance while at camp (getting dressed, showering, bathroom, etc.)?SelectYesNoIf yes, please explain what assistance will be required:Are there any custody issues we should know about?SelectYesNoIf yes, please explain. Please be specific:Please inform us of anything you'd like us to know about the camper. This includes any other health conditions, mental or physical, that will require treatment, restrictions, or any other accommodations while your child is at Camp Courage. Please be specific.COVID-19 Vaccination Card. Please upload your campers vaccine cards.Choose FileNo file chosenDelete uploaded fileHealth Insurance And Doctor InformationChild’s Pediatrician/Doctor: *Phone Number *Health Insurance InformationDo you have medical insurance? *SelectYesNoFull Name of Policy Holder: *Policy Holder Phone Number: *Employer Name (if insured through company): *Insurance Company/Plan Name: *Insurance Company Phone Number: *Health Insurance Policy Number: *Insurance Group Name or Number: *Please Fill out all of the information requested. A copy of the form above will be emailed to you. By writing your name below you agree to the following: (Parent/Guardian)o I certify that all information on this application is true and correct. o I have informed you of any special needs that will require attention during my child’s stay at camp. o I will review the rules and guidelines of expected behavior at Camp Courage with my child before his/her time at camp. o Because there is no regularly scheduled transportation, if for any reason it is determined by the Camp Courage staff that my child must leave before the end of his/her session, I agree to be responsible for his/her transportation from Camp within 12 hours.Signature *Start signing your signature hereYour browser does not support e-Signature field.Submit ApplicationSave as DraftPlease do not fill in this field.