NF Camp 2018 Application - Part One

To apply to the Children's Tumor Foundation NF Camp, please complete this form.

Tuition is $650, not including flights. CTF will follow up with you in regards to payment, once application is complete. If you wish to apply for a scholarship please indicate that at the end of this application.

Note that you will be asked to upload a copy of your camper's Health Insurance card or other proof of coverage. Please be sure this information available to upload before beginning the application, as you will be unable to save your work.



Please supply information for your camper that will be accurate and up-to-date as of August 3, 2018.

















If camper is no longer in school, please list current occupation (if applicable)


Please leave blank if camper does not have a separate email


Please leave blank if camper does not have a separate email. To help with our airport and arrival process.






If so, please include a link to the fundraising page. (Not required)





































Please upload a copy of insurance card or other proof of coverage at the bottom of this application.






















This information will assist our staff in best serving our campers. As well as, providing valuable information for state, federal, and private funding requests.



Please check all that apply






















How is your camper affected by NF?





























Has your camper had surgery or radiotherapy in the past year


Please give details (include specific medical issues, social adaptability, learning disabilities, etc)


Please list out all allergies


Please be very specific


Please be specific about which and when each medication should be administered








Please insert full name of your camper


Please insert full name of your camper


Insert parent or guardian's full legal name







Insert parent or guardian's full legal name






Discuss the contents with your teen to insure that they understand the importance of adhering to these rules


The CTF Code of Conduct is designed to insure the safety and well-being of all participants in the NF Camp Program. Please read it carefully and sign to indicate your readiness in abiding by all provisions. If you are under 18, your parent/guardian MUST also sign on the line provided. Please note that you will not be permitted to attend NF Camp unless the Code of Conduct & Responsibility has been received by the CTF office.

HEALTH & SAFETY – BETWEEN PARENT/GUARDIAN, CAMPER AND CTF:
CTF has spent much time and effort evolving what we believe to be the most appropriate policies to insure the health and safety of each individual participating in our programs. We expect and understand that as with all recreation/travel programs, young people may “act up” as teenagers do with the expected consequences. However, to insure the enjoyment for ALL campers, there are prescribed limits of personal behavior. This behavior code will be strictly enforced. Should a youngster be expelled from the program, understand that there is absolutely no refund of any monies paid and any expenses which may result from expenditures incurred in the process of separating the child from the program are due and payable.

Disciplinary action is not arbitrary and an attempt is made to be understanding and progressive in our approach. However, specific activities such as, but not limited to leaving the site without permission, physical and/or verbal acts threatening to other participants, destruction of property and theft and inappropriate sexual behavior are considered dangerous enough to warrant expulsion. Every effort is made to avoid this extreme action.

Please discuss the above and the accompanying CODE of CONDUCT & RESPONSIBILITY with your son/daughter. Please be certain that all participants understand its contents and seriousness.



CODE OF CONDUCT & RESPONSIBILITY


The following rules concern your responsibility to the group and to your counselors:
Full cooperation with your counselors is mandatory, and you are expected to treat them respectfully at all times
Property and privacy of others must be respected under all circumstances
You may not absent yourself from any part of the program or leave the property without the consent of your group leaders
You may not invite guests to join you for any part of the program without advance permission of your counselors
The following activities are strictly prohibited:
Sexual behavior
Vandalism, disturbing the peace or other inappropriate behavior (any damages incurred will be paid for by the person(s) responsible, and if under 21, by the parent/guardian)
Any behavior that threatens or harms another individual
Referring to any individual in a harmful or demeaning way (i.e. racial or sexual slurs and profanity)

I HAVE READ THE ABOVE CODE OF CONDUCT & RESPONSIBILITY AND AGREE TO ABIDE BY THEM. I UNDERSTAND THAT ANY VIOLATIONS OF THE ABOVE WILL BE DEALT WITH BY THE CTF REPRESENTATIVES AND/OR THE CAMP STAFF AND COULD RESULT IN MY BEING SENT HOME. I UNDERSTAND THAT ANY DECISION REGARDING MY POSSIBLE EXPULSION FROM THE PROGRAM IS AT THE SOLE DISCRETION OF THE CTF STAFF AND WILL BE AT MY (AND/OR MY PARENT/GUARDIAN’S EXPENSE).

Please insert camper's full legal name






I (We) have read the above CODE OF CONDUCT & RESPONSIBILITY with our child and agree with its provisions:

Please insert parent or guardian's full legal name






As the parent or legal guardian of the participant named below (the “Participant”), I understand that if he/she acts in a manner that Staff at Camp Kostopulos find harmful to self or others, I will be responsible for picking the Participant up and taking them home or will be responsible for the cost to remove the Participant from Camp until he/she can be taken home. I also understand that I am responsible for the actions of any third party chaperone accompanying the Participant. Camp Kostopulos requires a background check for any such third party chaperones, and I agree to reimburse Camp Kostopulos for any costs incurred by the Camp to perform such background check.

I understand that Camp Kostopulos is not responsible for articles that are lost or stolen while the camper attends camp. I understand that while the Participant attends camp that he/she may be responsible for damage done to Camp or personal property.

Waiver and Medical Release
The camp is not a medical facility. We will provide basic health care generally accepted in the camping industry. Parents/legal guardians are financially responsible for health care given by out-of-Camp providers.

I hereby affirm that I am the parent or legal guardian of the Participant, or I am the Participant and over 18 years of age, and that the information contained herein is correct and complete to the best of my knowledge. Except as I have provided to Camp Kostopulos on a Participant Information Sheet, the Participant has my permission and the permission of the child’s physician to engage in all camp-sponsored activities, such as, but not limited to: horseback riding, swimming, boating/canoeing, fishing, hiking, camping, sports, games, arts and crafts, dances, challenge ropes course and field trips, whether on or off camp property (collectively, the “Activities”). I fully understand and acknowledge that the Activities involve risks to the Participant, other participants and third parties, including, without limitation, bodily injury, personal injury, mental injury, illness, death, property damage, loss and other serious ailments that could lead to disability, death and potentially extensive medical expenses. I understand and acknowledge that these risks and dangers may arise from foreseeable and unforeseeable causes and may be immediate or delayed. I hereby voluntarily and expressly assume the risk of all injury, harm and liability resulting to the Participant, other participants and third parties from the Participant’s participation in the Activities, including any risks resulting from any actions or inactions of Kostopulos Dream Foundation, Camp Kostopulos and each of its volunteers, directors, officers, members, employees, agents, successors and assigns (collectively, “KDF”). I understand that KDF does not assume any responsibility for or have an obligation to provide the Participant with any type of insurance (including insurance to cover any personal injury, bodily injury, illness, death or property damage), and it is my responsibility to obtain any such insurance. As consideration for the Participant being permitted to participate in the Activities, the Participant (or the parent or legal guardian of the Participant) hereby voluntarily, for himself, his administrators, personal representatives, assigns, other participants and third parties, agrees to release, waive, discharge and hold harmless KDF from any and all claims, demands and causes of action, including, without limitation, claims for bodily injury, personal injury, mental injury, illness, death property damage, and other such losses in connection with the Participant’s participation in the Activities as a result of any actions or inactions of KDF, whether or not such claims demands or causes of action result or arise from the negligence, acts or omissions, of KDF.


Medical Authorization
I hereby give permission for the staff of Camp Kostopulos to administer medication as described in the medical screening form and or other medical forms provided. I give permission to the physician selected by Camp Kostopulos to order x-rays, routine tests and treatment related to the health of the Participant for both routine healthcare and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia or surgery for the Participant. I understand the information on this form, the Participant Information Form, the medical screening form and other medical forms provided will be shared on a “need to know” basis with Camp Kostopulos staff. I give permission to photocopy this form, the medical screening form and other medical forms. In addition, Camp Kostopulos has permission to obtain a copy of the Participant’s health record from providers who treat the Participant and these providers may talk with the Camp’s staff about the Participant’s health status.

Media Release
I hereby grant permission to record the Participant’s voice, photograph, video him/her for various promotion or information Camp Kostopulos or the Kostopulos Dream Foundation. The use may come in the format of television, newspapers, newsletters, brochures, radio, and/or other media. I release KDF from any liabilities arising from such media use. I understand that I (or my child) will not receive payment for these media uses.
Human Rights
Camp Kostopulos has a Human Rights plan that is designed to promote the protection of human rights, including rights under the Americans with Disabilities Act. I acknowledge that I have received a copy of the Camp Kostopulos Human Rights Plan and reviewed and understand it.
Division of Services for People with Disabilities (D.S.P.D.) Grievance Process
I understand that if I am not found eligible for services from this agency, or if I am not satisfied with the services received, I have a right to a hearing with D.S.P.D. I also understand that I have the right if services are terminated or if they are not made available to me with reasonable promptness. The grievance committee is part of the Social Services Department and may be reached through your caseworker. T h e r egional office is located at 195 North 1950 West Salt Lake City, UT 84116. Phone 801-538-4120. I understand the above grievance policy and agree to it.



Participant Name


Full Name of Legal Guardian







If Yes to the below, please answer the following questions. If No, please continue to the Attachment section of the application.


Will you be requesting a scholarship to attend camp?




If choosing a full scholarship please let us know which airports are best for your travel. Please note the larger will most likely have direct flights, which is ideal for campers flying alone.




Please explain below why you are requesting a scholarship, such as:
1) unusual medical expenses not covered by insurance, or
2) a family member who recently became unemployed, or
3) other changes in income, or
4) other factors that affect your financial ability to send your child to the 2017 CTF Summer Camp.






Please attach a copy of camper's health insurance card or other proof of coverage. You may also attach part two of the application - current health forms from the doctor, including an up-to-date physical and any other specifics related to the care of your camper. If you do not have part two completed, it may be emailed at a later date to jpantoliano@ctf.org. There is no limit to the number of attachments in this field (but each attachment must be smaller than 25 MB).






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