Family Registration Form - Kids Cancer Care

For Office Use:
Input Date:
Admin Initial:
Nurse Review Date Initial:
Coordinator Review Date Initial:
Director Review Date Initial:
Family Registration Form
The Kids Cancer Care Foundation of Alberta is passionately dedicated to helping children and
families affected by cancer survive and thrive in body, mind and spirit. Please take a few minutes
to fill out this form in its entirety. All information provided will be kept confidential and private.
DATE: ______________
FAMILY NAME: ______________________________________________
ADDRESS: ___________________________________________________
CITY: _______________________PROVINCE: ______________________
POSTAL CODE: _______________ PHONE: ( ) ____________________
FAMILY EMAIL ADDRESS: ______________________________________
A. FAMILY INFORMATION
Parent/Guardian 1 Name: ______________________________________
Address: same as family address above different from family address (please list below)
____________________________________________________________________
Phone: Home ( ) ____________ Work ( ) ________________ Cell: _____________
Email address if different from family email: _______________________________
Parent/Guardian 2 Name: ______________________________________
Address: same as family address above different from family address (please list below)
Phone: Home ( ) _____________ Work ( ) ______________ Cell: _____________
Email address if different from family email: _______________________________
KCCFA Family Intake Form
Revised 6/6/10
1

EMERGENCY CONTACT INFORMATION
Please provide contact information for two adults who KCCFA may reach during
camp/programs, in the event that neither parent/guardian can be reached during an emergency
situation. Please choose emergency contacts that will be available to pick up your child, in the
event that you are unable.
Emergency Contact One
Name:____________________
Phone:____________________
Emergency Contact Two
Name:____________________
Phone:____________________
Relationship to child :_____________________
Alternate Number:_______________________
Relationship to child :_____________________
Alternate Number:_______________________
EMERGENCY TREATMENT AUTHORIZATION
Please give KCCFA permission to provide emergency medical treatment to your child while at
camp/programs
I, ______________________ (parent/guardian) authorize emergency medical treatment
for my child/children if required.
__________________________
_______________________
Signature
Date
We typically provide information to families via email.
Please indicate that you wish to receive:
____ Camp & Program information
KCCFA Family Intake Form
Revised 6/6/10
2

CAMPER NAME:
____________________________
BIRTHDAY: ______/______/______ SEX: Male Female
Month Day Year
ALBERTA HEALTH CARE #:________________DR__________PHONE____________
CHILD HEIGHT:_________________ CHILD WEIGHT:_________________
RESIDES WITH: Mother Father Both Other - if other, please specify name/address:
____________________________________________________________________
CAMPER 2
____________________________
BIRTHDAY: ______/______/______ SEX: Male Female
Month Day Year
ALBERTA HEALTH CARE #:________________DR__________PHONE_____________
CHILD HEIGHT:_________________ CHILD WEIGHT:_________________
RESIDES WITH: Mother Father Both Other - if other, please specify name/address:
_____________________________________________________________________
CAMPER 3
____________________________
BIRTHDAY: ______/______/______ SEX: Male Female
Month Day Year
ALBERTA HEALTH CARE #:_______________ DR__________PHONE_______________
CHILD HEIGHT: _________________ CHILD WEIGHT:_________________
RESIDES WITH: Mother Father Both Other - if other, please specify name/address:
_____________________________________________________________________
CAMPER 4
BIRTHDAY: ______/______/______ SEX: Male Female
Month Day Year
ALBERTA HEALTH CARE #:________________ DR__________PHONE________________
KCCFA Family Intake Form
Revised 6/6/10
3

CHILD HEIGHT: _________________ CHILD WEIGHT:_________________
RESIDES WITH: Mother Father Both Other - if other, please specify name/address:
_____________________________________________________________________
CAMPER SWIMMING ABILITIES:
Please indicate the current swimming level or ability for each child, as well as the accrediting body. This
information is required to ensure waterfront safety and appropriate programming while at camp or at
public swimming facilities.
SWIM LEVEL
ACCREDITING BODY
(Red Cross, YMCA, etc.)
Camper 1 Camper 2 Camper 3 Camper 4
**FOR ADDITIONAL SIBLING INFORMATION, PLEASE USE BACK OF SHEET**
PRIORITY SYSTEM
When spaces are limited for camps and programs, KCCFA gives priority to children and families who are
recently diagnosed, recently bereaved, or who have never been to camp before.
Please select the appropriate priority that applies to your family.
Priority 1
o Parent currently on treatment or recently bereaved
Priority 2
o Parent off treatment for less than five years
Priority 3
o Parent off treatment for more than five years
FAMILY PHYSICIAN:
Priority 4
____________________________________________
o Special considerations for campers who do not meet any other criteria, with
Phone: ____________________ approval of the KCCFA City: camp ______________________
team
B. HEALTH AND MEDICAL INFORMATION
KCCFA Family Intake Form
Revised 6/6/10
4

Please rate the current state of health for each camper
Current state of health
(on treatment, poor, fair,
good, excellent)
Camper 1 Camper 2 Camper 3 Camper 4
Please indicate if each child has any allergies:
Allergy Type Camper 1 Camper 2 Camper 3 Camper 4
Medication Allergy
(e.g. to penicillin, morphine)
Environmental Allergy
(Pollen, Dust, Bees etc)
Please indicate if each child has any food allergies or dietary restrictions:
Camper 1 Camper 2 Camper 3 Camper 4
Food allergy
(e.g. peanuts, lactose)
Dietary Restriction
(e.g. vegetarian, celiac)
Is camper aware of dietary
restrictions or allergies?
Please indicate if your child (ren) currently experiences any of the following:
Concern: Camper 1 Camper 2 Camper 3 Camper 4
KCCFA Family Intake Form
Revised 6/6/10
5

Headaches
Convulsions / seizures
Fainting spells
Vision problems
Glasses and/or contacts
Hearing problems
Wears hearing aids
Asthma – non-medicated
Asthma – takes medication
Heart problems
Blood clotting problems
Stomach/bowel problems
Skin problems
Menstruation – has started
Menstruation problems
Diabetes
Motion sickness
Physical limitations or
disabilities
Uses physical aides
(e.g. prosthetic, wheelchair,
crutches etc)
G-Tube/ NG –tube
Bed wetting
Other
Please indicate if your child has experienced any of the following in the past:
Concern: Camper 1 Camper 2 Camper 3 Camper 4
Seizures/convulsions
Heart/lung problems
Blood clotting problems
If you answered yes to any of the above you must expand on the information provided above and/or explain any
other medical/physical areas of concern for your child:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
KCCFA Family Intake Form
Revised 6/6/10
6

Please indicate if each child has had the following illnesses, and the date:
Illness: Camper 1 Camper 2 Camper 3 Camper 4
Chicken Pox
Shingles
Measles
Hepatitis
MRSA
Other communicable diseases
Please indicate if your child has been immunized for any of the following:
Immunization: Camper 1 Camper 2 Camper 3 Camper 4
Varicella
(chicken pox)
MMR
(measles, mumps, rubella)
Polio
DPT
(Diphtheria, polio, tetanus)
Hep B
(Hepatitis B)
Tetanus
C. CAMPER BACKGROUND INFORMATION
While KCCFA camps and programs are places for kids to get away from worries and troubles, sometimes what is
going on in their everyday lives affects their ability to have fun at camp. Thus, we would like you to provide some
background information about your child (ren), so that we are well-equipped to support them. This information will
be kept private and confidential with KCCFA, shared only on a need-to-know basis with their counsellors/volunteers
at camp/programs.
Please explain if your child (ren) has experienced the following and provide any information that would help
us support them.
Divorce/separation
KCCFA Family Intake Form
Revised 6/6/10
7

Moved within the last year
Difficulty with peers
Diagnosis/treatment for mental health issues
Has particular fears
Recent death (family, friend, pet)
Difficulty in dealing with parent’s cancer or other difficulties
D. EXTRA SUPPORT
In order to ensure that each child has the best camp experience possible, KCCFA offers extra support for children
requiring individualized assistance. Please indicate if any of the following apply to your child (ren), or if your child
(ren) needs extra support for any other reason. Our outreach coordinator will contact you directly for more detailed
information.
Name of camper: _________________________________
Physical, mental, developmental disabilities, disorders or delays
Behavioral issues/concerns
Health concerns
Night time concerns
Other reasons for extra support
Please elaborate on the needs that your child may have at camp and the individualized assistance they may require:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
F. CONFIRMATION OF INFORMATION
I confirm that the information I have provided in this form is accurate and current.
Parent/guardian (please print) Signature Date
KCCFA Family Intake Form
Revised 6/6/10
8

G. PUBLICITY RELEASE
The Kids Cancer Care Foundation of Alberta (“KCCFA”) is a not-for-profit society that provides camps and
community programs to families affected by cancer.
KCCFA utilizes digital media, photographs and video records of KCCFA’s activities for our annual report, website
and for publicity and fundraising ventures. These promotional materials are used to assist us with fundraising,
volunteer recruitment, raising awareness of childhood cancer and promotion of camps and programs. Successful
promotion allows us to provide camps to children and families. When we use images from KCCFA’s activities for
such promotional purposes, we do not use family names when identifying individuals, only first names.
Parents or Guardians:
I/we, _________________________, (Printed name(s)), on my/our own behalf and as parent/s or guardian/s of
___________________________________ (Child/Children’s names) hereby authorize the use of digital,
photographical or video images in my /our likeness(es) and that of our child/children for the purposes as listed
above. KCCFA will make every reasonable attempt to contact parents whenever any feature presentation includes a
prominent photo of their child.
Parent/Guardian Signature ________________________
Date: ______________________________
All pictures and videos remain the property of KCCFA.
Privacy
The Kids Cancer Care Foundation of Alberta (KCCFA) respects your privacy. We protect your personal
information and adhere to all legislative requirements with respect to protecting privacy. We do not rent, sell or
trade our mailing lists. The information you provide will be used to deliver services and to keep you informed and
up to date on the activities of KCCFA, including programs, services, special events, funding needs or opportunities
to volunteer. If at any time you wish to be removed from any of these mailing lists, simply contact us by phone at
403.216.9210 or via e-mail at staff@kidscancercare.ab.ca and we will gladly accommodate your request.
Our Mailing Address:
Kids Cancer Care Foundation of Alberta
609 - 14 Street NW, Suite 302
Calgary, Alberta T2N 2A1
Fax: 403.216.9215
Our website: www.kidscancercare.ab.ca
For General KCCFA Program Inquiries:
Mike MacKay
Director of Camp & Community Outreach
Phone: 403.984.1220
Toll Free: 1.888.554.2267 ext. 223
Email: mackay@kidscancercare.ab.ca
KCCFA Family Intake Form
Revised 6/6/10
9

2010 SUMMER CAMP SESSIONS
Parents please indicate which camp your child or children will attend.
Session 1 - August 2 – August 6, 2010
Session 2 - August 9 – August 13, 2010
Cost of camp - $400.00/camper payable by:
• Cheque (payable to the Kids Cancer Care Foundation of Alberta)
• Credit card
• Money order
KCCFA Family Intake Form
Revised 6/6/10
10