General Application Play Pause Unmute Mute This application is for the siblings and junior counselor volunteers that do not have cancer/history of a cancer diagnosis.To be completed by the parent/legal guardian. Camper InformationCamp Courage is a free camp for kids ages 7-15 who have cancer, are cancer survivors or are siblings to a child with cancer. The sibling/general application asks for information about siblings or junior counselor volunteers (without a cancer history) that would like to attend camp. The application requires health history information and must be complete by the parent/legal guardian. All applications must be submitted by 6/30/26. *Note* at this time, we can only accept application for two siblings in a single family to attend camp. If more siblings would like to attend, or for any other questions, please email us as campcouragecolorado@gmail.comFirst Name *CamperLast Name *CamperBirthday *CamperEmail AddressCamperPhone NumberCamperAge *Camper (during camp)Grade This Fall Semester *Select1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th GradeFreshmenSophomoreJuniorSeniorCamperGender *SelectMaleFemalePrefer not to sayOtherCamperT-Shirt Size *SelectYouth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult XLAdult 2XLOtherCamperHow did you hear about our organization?Has your child attended Camp Courage before? If yes, how many times?Will a sibling be joining this camper at camp? If yes, please type how many and the sibling(s) full nameIf yes, please complete a primary application for every sibling with a cancer diagnosis or general application for every sibling without a cancer diagnosis.Parent/Guardian #1First Name *Parent/Legal GuardianLast Name *Parent/Legal GuardianStreet Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Country *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 DemocraticZambiaZimbabwePhone Number *Parent/Legal GuardianEmail Address *Parent/Legal GuardianEmployerParent/Legal GuardianParent/Guardian #2This section can be skipped if this child only has one parent/legal guardianFirst NameParent/Legal GuardianLast NameParent/Legal GuardianStreet 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 DemocraticZambiaZimbabwePhone NumberParent/Legal GuardianEmail AddressParent/Legal GuardianEmployerParent/Legal GuardianHousehold InformationFamily Status *SelectMarriedDivorcedSeparatedSingle MotherSingle FatherOtherCustody *SelectMotherFatherJointGrandparent(s)Guardian(s)OtherAre there any custody issues we should know about? If yes, please explain.Emergency Contact #1Parent(s)/legal guardians(s) will always be contacted first in an emergency. If we are unable to reach you, we need two additional individuals to contact in case of an emergency. Please do not put yourself as the emergency contact.First Name *Emergency ContactLast Name *Emergency ContactRelationship to camper *Phone Number *Emergency ContactEmergency Contact #2Parent(s)/legal guardians(s) will always be contacted first in an emergency. If we are unable to reach you, we need two additional individuals to contact in case of an emergency. Please do not put yourself as the emergency contact.First Name *Emergency ContactLast Name *Emergency ContactRelationship to camper *Phone Number *Emergency ContactHealth 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.First Name *CamperLast Name *CamperHeight *CamperWeight *CamperDate of last well child check/annual exam *CamperDoes the camper have any allergies? If yes, please list allergy and the associated allergic reaction. *CamperDoes the camper require an EpiPen? If yes, please provide the date and a description of the most recent incident. *CamperDoes this camper have any dietary restrictions? If yes, please explain:CamperMedications and TreatmentsMedications brought to camp must be in it's original packaging. Any medication not in it's original packaging, will have to be sent home with the parent/legal guardian. The camp medical staff will be collecting camper medications at drop-off.Will the camper be taking any medications while at camp? If yes, provide the drug name, dose amount, frequency, and reason for taking medication. *CamperMedications 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: *CamperWill the camper require any other type of treatment while at camp? If yes, please explain the treatment, frequency, and how it should be administeredCamperDoes the camper regularly take medications that they are not bringing to camp? If yes, please explain.CamperImmunization 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 fileFor security reasons, the following file types are the only ones accepted: .pdf .jpeg .doc (Files must be less than 10 MB)Diptheria, 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:Does the camper get homesick or have separation issues when away from home? *SelectYesNoIf yes, please explain:Does the camper have anxiety, depression, or an eating disorder? *SelectYesNoIf yes, please explain:Does the camper have asthma, problems breathing, coughing, or lung disease? *SelectYesNoIf yes, please explain the severity of the condition, triggers, and if they will require an inhaler.CamperDoes the camper have seizures, epilepsy, convulsions, fainting, or blackouts? *SelectYesNoIf yes, please provide information including the frequency, date of last episode, description of what it looks like, and any other relevant information.CamperDoes the camper have mobility issues, difficulty walking, use a wheelchair, use braces/walker, have a prosthesis, or have prosthetic joints? *SelectYesNoCamperIf yes, please provide information including: How often they will need the equipment.CamperDoes 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/injury? *SelectYesNoIf yes, please explain:Does the camper have stomach or intestinal problems (Crohn’s/Colitis/Constipation/Diarrhea/Ulcer)? *SelectYesNoCamperIf 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 frequent 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:Is there anything else you would like us to know about this camper (other medical conditions, accomadations, behavioral concerns, interests, dislikes, etc.) Please be specific.CamperPrimary Care InformationName of Pediatrician/Primary care provider. *Name of Pediatrician/Primary care clinic *Phone Number *Health Insurance InformationDoes your camper have medical insurance? *SelectYesNoInsurance Company/Plan Name:Insurance Company Phone Number:Insurance Group Name or Number:Health Insurance Policy Number:Full Name of Policy Holder:Policy Holder Phone Number:Employer Name (if insured through company):Permission for Media (Photos & Video)Permission for photographs and interviews of campers under 18 years of age can be granted to the media ONLY with parent/guardian approval. These photographs, written interview quotes and verbal interview statements will appear in information about Camp Courage programs and people. I understand that Camp Courage shall not be liable for royalties, commissions, or payments of any nature to me or my child in connection with such filming, photographing, and/or interviewing. Camp Courage assumes no liability of any nature in connection with such filming and/or interviewing. I hereby give permission to Camp Courage to allow my child to be filmed/photographed and interviewed by the media.Select *Please select an optionI do give permissionI do not give permissionDo you give permission to Camp Courage to allow your child/children to be filmed/photographed and interviewed by the media?Signature of Parent/GaurdianStart signing your signature hereYour browser does not support e-Signature field.Please sign if you agree to give Permission for Media (Photos & Videos)Please Fill out all of the information requested. 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 of Parent/Guardian *Start signing your signature hereYour browser does not support e-Signature field.Parent/Legal GuardianWaiver and Release of LiabilityIn consideration of being allowed to participate in Camp Courage (“Activity”), to the extent permitted by law I hereby forever discharge, release, and hold harmless School District No. 1, in the City and County of Denver and State of Colorado (the “District”), and its employees, officers, directors, agents, representatives, and authorized volunteers (collectively, the “Releasees”) from any and all liability, claims, demands, actions, and causes of action arising from or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, while participating in the Activity. I am fully aware of the potential risks and hazards and I hereby elect to voluntarily participate in the Activity. I knowingly and freely assume all potential risks, known and unknown, including those arising from the negligence of the Releasees. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, further agree to indemnify and hold harmless the Releasees from any loss, liability, damage or costs, including court costs and attorneys’ fees, that Releasees may incur due to my participating in the Activity, including those caused by the negligence of the Releasees or otherwise. I have read this Waiver and Release of Liability (“Agreement”) and fully understand its terms. I also understand that I have given up substantial rights by signing it and sign it freely and voluntarily without any inducement. I am at least eighteen (18) years of age and fully competent to sign this Agreement.Signature of Participant *Start signing your signature hereYour browser does not support e-Signature field.ParticipantSignature of Parent/Guardian *Start signing your signature hereYour browser does not support e-Signature field.Parent/Legal GuardianDateWAIVER, RELEASE AND ASSUMPTION OF RISK BALARAT Challenge Elements/DENVER PUBLIC SCHOOLSThe Denver Public Schools’ Balarat Challenge Elements are part of an experiential education program that offers groups and individuals the opportunity to engage in personal development and team building activities. A challenge course, commonly known as a ropes course, is composed of wooden frameworks, cables, and belay systems that are used for the facilitation of the aforementioned activities. As a participant at the Balarat Challenge Elements (the Course), I agree as follows: My participation should be within my own physical, emotional, and other limitations. The Course consists of physically demanding elements that involve bending, twisting, lifting, swinging, balancing, and climbing to heights of approximately 40 feet. The Course will involve contact with others and harnesses that may induce pressure on my hips, back, chest and stomach. The physical exertion can be intense, involving increased heart and breathing rates. There are unforeseen risks inherent in these physically demanding activities. Additionally, the Course is outdoors, thus may be exposing me to extreme heat/cold, sunlight, dangerous weather, dehydration, bugs, spiders, ticks and other potentially harmful factors. I acknowledge that when participating in these activities there is a possibility of physical injury. I acknowledge that I can elect not to participate in part or all of the activities. I agree to consult with my personal physician before participating or I acknowledge that I have voluntarily declined to do so. If I choose to participate in the Course activities, I do so voluntarily and at my own risk. I personally assume all risks associated with being a participant on the Course, whether or not that risk is specifically noted herein. I acknowledge and assume all medical expenses that may arise related to my participation and acknowledge that no medical insurance is being provided by or through the “releases” outlined below. I waive, release and discharge for myself and my heirs, executors, administrators, legal representatives, assigns and successors, Denver Public Schools and all their agents, officers and employees (collectively referred to as “releasees”) from all claims, demands, and causes of action of any kind, including claims for negligence which may arise from or be related to my participation at the Course. As a participant, I acknowledge my responsibility for my, and others, safety and will follow the safety criteria established by DPS/Balarat staff. Failure to do so may result in restrictions and/or my dismissal from the Course. My signature below binds my heirs, executors, administrators, legal representatives, assigns, successors and me. By signing below I agree that I have carefully read and assent to all of the terms stated above. If I am signing as a parent/guardian/legal representative, I agree on the minor’s behalf.Signature of Participant *Start signing your signature hereYour browser does not support e-Signature field.ParticipantSignature of Parent/Guardian *Start signing your signature hereYour browser does not support e-Signature field.Parent/Legal GuardianDateSubmit ApplicationSave as DraftPlease do not fill in this field.