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Virtual Camp Dates: June 20th - August 11th

We are thrilled to welcome you and your child(ren) to SunriseVX 2023, our Virtual Camp eXperience – free of charge – for child(ren) with cancer, ages 3 1/2 -16 and their siblings.

Please note - if you intend to register for in-person camp for Summer 2023, click here. The application below is intended for families choosing to enroll their child(ren) in our virtual camp experience.

For any questions regarding SunriseVX, please contact Athena Levesque at sunrisevx@sunriseassociation.org.

Basic Info

Email address for registration (you will receive a confirmation email to this email address) *

Phone Number *

Preferred method of contact *

Mailing Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

How did you hear of SunriseVX? *

If other, please explain: *

Camper Info

Once enrolled, all campers are welcome to attend all VX programs throughout the year.

**If you are a returning Virtual or In-Person Camp family, please indicate which camp location your child(ren) has previously attended** *

Child with cancer/Camper #1 *

	First Name	Last Name	Gender	Date of Birth	2023-24 School Grade	School	New or Returning Camper	Language (if other than English)
Camper #1	First Name	Last Name	Gender	Date of Birth	2023-24 School Grade	School	New or Returning Camper	Language (if other than English)

Camper #1 Pronouns (Optional)

Are you registering more than one camper? *

Yes

No

Camper #1 Photo

Siblings

	First Name	Last Name	Gender	Pronouns (Optional)	Date of Birth	2023-24 School Grade	School	New or Returning Camper
Camper #2	First Name	Last Name	Gender	Pronouns (Optional)	Date of Birth	2023-24 School Grade	School	New or Returning Camper
Camper #3	First Name	Last Name	Gender	Pronouns (Optional)	Date of Birth	2023-24 School Grade	School	New or Returning Camper
Camper #4	First Name	Last Name	Gender	Pronouns (Optional)	Date of Birth	2023-24 School Grade	School	New or Returning Camper
Camper #5	First Name	Last Name	Gender	Pronouns (Optional)	Date of Birth	2023-24 School Grade	School	New or Returning Camper

Preferred Language *

What language(s) does your child speak? *

Camper #2 Photo

Camper #3 Photo

Camper #4 Photo

Camper #5 Photo

Do any of your children have an IEP/504 plan? Please note which camper(s) and any relevant information below: *

Medical Info

Initial Cancer Diagnosis *

Diagnosis Date *

On Active Treatment? *

Yes

No

Date Treatment Ended *

Primary Hospital where Camper #1 has received treatment *

Social Worker/Hospital Contact Info

Social Worker Name

Social Worker Phone

Social Worker Email

Referring Oncologist Contact Info

Oncologist Name

Oncologist Phone

Oncologist Email

Primary Care Physician Contact Info

PCP Name

PCP Phone

PCP Email

Parent/Guardian Info

Parent/Guardian #1 Contact Information *

	First Name	Last Name	Relationship	Gender
Parent/Guardian #1	First Name	Last Name	Relationship	Gender

Email *

Cell Phone *

Work Phone

Preferred Language? *

English

Spanish

Other

Please list the preferred language(s): *

Parent/Guardian #1 Occupation

Parent/Guardian #1 Place of business

Parent/Legal Guardian Marital Status

Parent/Guardian #2 Contact Information

	First Name	Last Name	Relationship	Gender
Parent/Guardian #2	First Name	Last Name	Relationship	Gender

Preferred Language?

English

Spanish

Other

Please list the preferred language(s):

Parent/Guardian #2 Occupation

Parent/Guardian #2 Place of business

Family Demographic Information

The following is for use by the Sunrise Association when applying for funds from various sources and will not affect your ability to attend camp for free, regardless of your income.

Information that we provide to third parties will never identify you nor your family members but will rather be grouped together with other families’ as part of overall statistics.

Family Ethnicity

Please indicate

Family Income

Virtual Camp Info

I hereby give permission for my child(ren) to be contacted directly, either by text message and/or email, for virtual camp program reminders: *

Yes

No

Camper Contact Info

Camper Contact Info *

	Camper Name	Cell Phone
Camper #1	Camper Name	Cell Phone

Camper #1 Email *

Camper Contact Info *

	Camper Name	Camper Cell Phone
Camper #2	Camper Name	Camper Cell Phone
Camper #3	Camper Name	Camper Cell Phone
Camper #4	Camper Name	Camper Cell Phone
Camper #5	Camper Name	Camper Cell Phone

Camper #2 Email *

Camper #3 Email *

Camper #4 Email *

Camper #5 Email *

Permissions

I acknowledge and accept that my child(ren)/family may be participating in video activities and webinars that may include them being seen and heard on a webcam over the internet. *

Yes

I acknowledge and accept that Sunrise VX/Sunrise Association will be using a third-party platform like Zoom to facilitate video sessions and I agree that Sunrise VX/Sunrise Association assumes no liability for any performance issues with Zoom or any other third-party software. *

Yes

I will encourage my child(ren) to follow appropriate online conduct as explained to them and written in the parent manual or risk losing privileges to participate *

Yes

I acknowledge and accept that others may see our home environment during live sessions. *

Yes

By allowing your child to participate in our virtual program, you are granting Sunrise Association Camps the right to use such images and/or recordings.I acknowledge and accept that virtual camp program sessions may be recorded from time to time, and that all or portions of such recordings/images may be used for purposes including but not limited to sharing with children and families, staff and/or potential staff, teaching and training, and/or marketing/fundraising. *

Yes

These authorizations are limited to the date signed below through July 1st of the following year. By signing below, I agree to signing this release and the items as initialed above *

clear

I hereby give permission for my child(ren)’s name(s), family address, phone number and email to be listed in the camp directory and distributed to camper families in the Sunrise Association Camps community. *

Yes

No