Wufoo

Child (camper) application form

This form is to be completed by all children applying to come on a Camp Quality UK holiday. We may need to contact the child's consultant to gain more information.

In order to make appropriate decisions, this is quite a long form, it may take upto 20 minutes to complete.

Not all information is appropriate for every child, so please read the instructions carefully at the start of each section and when you hover over each field (where handy tips may appear on the right)

Which holidays would you like to apply for?
2009 holidays - any 2009 - Spring (details to be confirmed) 2009 - Summer (details to be confirmed) 2009 - Autumn (details to be confirmed)
Child's details (1 of 7)

Child's name, contact details and date of birth
Child's name * First Last
Address line 1 *
Address line 2
City (postal town) *
Postcode *
Main telephone number *

We will use this as your main number (this is normally the house phone number)
Email address for either parent

or guardian
Date of birth * / DD / MM YYYY
Example: If you were born on 1st March 1990 enter: 01/03/1990
Sex
Male Female
Parents (2 of 7)

If the child does not live with their parents, please complete the male and female guardian's details in the father and mother fields.
Primary parent/guardian's name Title First Last Suffix
Choose the main contact who we can contact about the child
Is this the child's mother or father (or other), please specify
Mother Father Other

This is just so we know who to send application forms to. This can be changed at a later date.
... other (please specify here)
Mother's mobile number

Or other female guardian
Father's mobile number

Or other male guardian
Address of other parent if different to the child's

Please state which parent lives here
Emergency contact details - if parents are unavailable (3 of 7)

If we are unable to get in contact with the parent's we need details for someone else.
Name of emergency contact First Last
Relationship to child
House phone
Mobile phone
Office phone
Medical information (4 of 7)

An overview
Date of initial cancer diagnosis / DD / MM YYYY
When you were first told your child had cancer (if you're unsure of the day, just put "01" for day)
Diagnosis

ie: Neuroblastoma, Acute Lymphocytic Leukaemia
Which of the following apply to your child? (Please give further details below)
Is neutropenic Is anaemic Has low platelets (thrombocytopenic) Has a Hickman/central line If they have a central line, does it need flushing? Has a PEG feed Is currently on treatment (please give details below) Is unable to swim (please give details below) Has balance difficulties (please give details below)
Further details on the above to be entered here. Please also list any restrictions on what your child can do or anything else we should know.

Please let us know, for example, if the child get's tired easily, will be neutropenic or cannot swim due to central line.
If child is off treament, give date of last course / DD / MM YYYY
Leave blank if child never on treatment (if you're unsure of the day, just put "01" for day)
Does your child have any allergies or other medical conditions? Please give details
Name of your child's consultant Title First Last Suffix
Primary consultant (oncologist, haematologist or palliative care consultant) responsible for your child's treatment who we may contact to confirm these details or gain further information.
Hospital where treated

If treated at several centres, please list where your child's (medical) oncologist is based
Address line 1 of consultant
Address line 2 of consultant
City (postal town)
Postcode
Telephone number
A little more info (5 of 7)

We'd like a fuller picture of your child to enable us to serve them better
How has your child been coping with cancer and all it's effects?
What do you or the child hope that they will gain from a Camp Quality UK holiday?
Is there anything else we need to know?

ie, has the child been bullied?
What is the child's shirt/chest size (in inches)? Please enter a number only

The child may be given a t-shirt or poloshirt at camp?
Please list any previous Camp Quality holidays that your child has attended
Please tick if you would like a sibling to be considered if we have spare spaces
Yes

Our standard policy is for siblings not come on Camp Quality holidays, in order to allow us to help as many children with cancer as possible
A bit about you (6 of 7)

So we know who we're talking to
Are you the child's legal parent or guardian?

If "Yes" please skip to section 8 "The legal stuff"
If you're not the child's legal parent or guardian please list your name, job title, address, telephone number and email address here

So that we may contact you with more information
The legal stuff (7 of 7)

Please read the following very carefully
I agree to my child’s attendance at Camp Quality UK holiday(s), and to his/her taking part in the activities, travel and excursions arranged in connection with these holidays.
I agree to my child's details being used to process their application and ensure their care on holiday.
I agree that Camp Quality UK may speak to relevant agencies and professionals to process my child's application and ensure their safety and medical care. *
I agree
After each holiday every family is sent a CD of the photographs taken during the camp, so that they and the child can look back on the holiday. We may also use these photographs for publicity and promotional purposes for Camp Quality UK. Are you happy for photos which show your child to be used in this way?
Yes No
Do Not Fill This Out

Wufoo

Child (camper) application form

Child's details (1 of 7)

Parents (2 of 7)

Emergency contact details - if parents are unavailable (3 of 7)

Medical information (4 of 7)

A little more info (5 of 7)

A bit about you (6 of 7)

The legal stuff (7 of 7)