Family Registration Form - Kids Cancer Care

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
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