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PO Box 412, Highland, IL 62249, USA

Ph: (618) 654-4020- St. Louis

  (941) 302-8412-Florida

Fax: (618) 654 4499

Camp HIS KIDS Camper & LIT Application 
Please complete one separate application per camper. Allow 15-20 minutes to complete this application. It's long, but bear with us-all of that info helps us to take better care of your child at camp! Click submit at the end to finish the form.
Which camp are you applying for?
For LIT campers only: which applies to you?
Has this child attended camp before?

CAMPER/LIT INFORMATION

Gender
Status of Treatment
T-shirt size

Please list first and last names and ages for any siblings below.

In case of emergency, please list 2 other people we could contact. (Relative or friend other than parents).

Immunization & Health Information

Tetanus Booster Up-To-Date?
MMR Vaccine Up-to-date?
Polio Vaccine received as a child?
Has your child received all vaccinations on a physician-recommended schedule (Per CDC Vaccine schedule)?

Note: We understand that treatments can affect vaccine schedules and this will not affect camp, but if this is the case, please explain details here. 

Will your child receive any vaccinations within 30 days of camp?

If yes, please note vaccine name and date below.

Has camper/LIT spent the night away from home before?
Does the camper/LIT have parental permission to swim?
Please check all that apply
If your child has asthma, does your child carry an inhaler?
Has the camper/LIT been exposed to chicken pox or other communicable diseases within 12 months prior to camp?
Has your child had...? (check if yes)

Any known allergies? (list all allergies to medications, food, animals, etc. and severity of reaction.

List any special diets and/or dietary restrictions below.

Any diarrhea and/or constipation? (If so, what do you do about it?) 

What is your child's current treatment (or past treatment)? If a sibling, does your child have any medical condition that we should be aware of? 

Please explain in detail every medication (inc. shots, inhalers, etc.) and other medical care you are presently doing at home for this child that the nurses will need to know for camp.

NOTE: we realize that things change quickly with treatments, and are happy to have you update medical information closer to camp if needed. This just provides a base for the nurses in their camp planning. 

Does your child have a central line? (Broviac, Port, PICC line, etc.)? What type? What dressings are applied? Describe the procedures and supplies below.

Social/Psychological Information

The following questions are very important in providing the best camp experience possible for your child. Please answer them in full detail, to the best of your ability for patients and siblings.

Is there anything else we should know about your child that would be helpful to medical staff and counselors in the physical care and/or emotional nurturing of your child? 

How do the illness and side effects seem to affect this child? (Please answer for siblings too)  Ex: running, walking, depression, angry, jealous, loss of friends, etc.

What does your child know about their/their sibling's illness or condition? Their/thier siblings diagnosis/prognosis? How has your child received this information? 

How has the cancer diagnosis affected your family? 

How has the cancer diagnosis affected this child personally? 

The following 3 questions are to be completed by LIT applicants only. Please have the LIT (not the parent) answer in their own words. If needed, answers may be emailed separately to jbellamy@hiskidsinc.org 

1. Why do you want to be in the Camp HIS KIDS Leaders in Training Program?

2. Describe what it means to you to be a "good leader." 

3. Please list any past experience, talents, or personal qualities which would make you a good candidate for this program. 

ALMOST DONE! A couple final questions to finish the legal releases and you're done! 

Please choose one option

If you chose option 2, we will email you the form that must be completed and signed by your child's physician.

MEDICATION RELEASE

The parents/legal guardians of the said participant hereby give permission to the medical personnel selected to administer prescribed medication, perform or assist with central line care, and any dressings. The undersigned authorizes the selected medical personnel to administer Tylenol, Benadryl, Ibuprofen, Mylanta, Rolaids, stool softener, and any other over-the-counter medication as needed. 

Are there any tricks to medication taking? ex:only likes liquid meds, chocolate milk to swallow pills, pills split in half, etc.

EMERGENCY AUTHORIZATIONS & RELEASE OF LIABILITY/PUBLICITY

In signing below, you are authorizing your permission for the following 3 items:

1. LIABILITY & TRAVEL

I hereby affirm that I have been well advised and thoroughly informed of the inherent and potential dangers of travel. By signing this release, I certify that I am cognizant of those basic risks and dangers. I understand and agree that neither the following agencies, organizations, or institutions and/or their sponsors: St. Louis Children's Hospital, Washington University, Cardinal Glennon Children's Hospital, St. John's Mercy Medical Center, Camp Wartburg, HIS KIDS Cancer Support nor their officers, servants, agents, employees, or volunteers may be held liable in any way for any occurrence in connection with a HIS KIDS Cancer Support sponsored/directed event which may result in injury, death, or other damages to myself or a member of my family. I hereby personally assume all risks in connection with said program/event, transportation, or use of materials, buildings and environment, for any harm, injury or damage which may befall myself or a member of my family, while participating in said program/event including all risks connected therewith, whether forseen or unforseen; and further to save and hold harmless said program/event and persons from any claim by me, or my family, estate, heirs, or assigns arising out of my enrollment and participation in said program. 

2. PUBLICITY

I give consent and permission for St. Louis Children's hospital, Cardinal Glennon Children's Hospital, HIS KIDS Cancer Support to use our authorize the use of any photos, interviews, or other publicity related items.

3. EMERGENCY/MEDICAL

I hereby give permission to the medical personnel selected by the staff of St. Louis Children's Hospital, Washington University, Cardinal Glennon Children's Hospital, St. John's Mercy Medical Center, Camp Wartburg, HIS KIDS Cancer Support or their volunteers to order x-rays, routine tests, an treatment for my child and in the event I am unable in an emergency/cannot be reached. I hereby give permission to the physician selected to hospitalize, secure proper treatment for and to order injection and/or surgery for my self/child as named below. The parents or legal guardian of the said attendee hereby gives permission to the medical personnel selected to administer prescribed medications, perform or assist with central line care, and any dressings. The undersigned authorizes the selected medical personnel to administer Tylenol, Benadryl, Ibuprofen, Mylanta, Rolaids, stoll sool softener, and any other over the counter drugs. The undersigned hereby authorizes HIS KIDS Cancer Support through its agents and servants to seek and have administered emergency medical treatment and care at a medical facility selected by HIS KIDS Cancer Support, Through its agents and servants, HIS KIDS Cancer Support shall use reasonable effort to contact the undersigned with regard to said emergency treatment or care.

Do you anticipate that your child will need a blood draw/counts during camp?

If yes, we will email you the blood draw information form to complete.

Is your child applying to be an LIT?

If yes, we will email you the LIT release form from Camp Wartburg, which gives permission for your teen to participate in the high ropes challenge course.

Please upload a copy/photo of your child's medical insurance card (front and back) below.

Upload med card front
Max File Size 15MB
Upload med card back
Max File Size 15MB

NOTE: If you do not have insurance, please let us know. This does not dis-qualify your child from camp, it will just be noted in place of insurance card. 

Please note that submitting this form does not guarantee a spot at camp for your child. You will receive confirmation or wait list notification in the coming weeks. Electronically sign below if the above information is correct to the best of your knowledge.