Joshua's Camp Family Retreat Application

Application for Joshua's Camp Family Retreat

If interested in your family attending one of our Joshua's Camp Family Retreats (Fall or Spring) in Eau Claire, Wisconsin - please complete the initial application form below. Additional information may be requested as needed to ensure your family retreat camp experience is safe, impactful, and meets your needs.

Today's Date

Month

Day

Year

Full Name Completing Application

Family's Residential City, State, Zip

E-mail Contact

Phone Contact

Parent(s)/Guardian(s) Full Name(s)

Additional E-mail

Who referred you to Joshua's Camp (name, position, contact information)

Treatment Child (full name)

Child's Date of Birth

Month

Day

Year

Gender

Female

Male

Non-Binary

Child's Diagnosis Summary

Initial Diagnosis Date

Current Treatment Process

Last Treatment Date

Primary Medical Treatment Facility (name, city, state, zip)

Physician or medical professional (name, facility, contact information)

Additional Physician or medical professional (name, facility, contact information)

Please list all the family members planning to attend the Joshua's Camp Family Retreat (Full Name, Age, Relationship to Child)

Child's Conditions: Please describe child's over-all condition and or any special needs or considerations (food allergies, wheelchair, other mobility, hearing, site, oxygen use, one-to-one attention)

Please describe any other medical concerns or accommodations needed for any of the Joshua's Camp participants

Please describe any other allergies of any of the Joshua's Camp participants

Emergency Contact of someone not attending the camp (name, relationship to family, phone)

Any special talents, hobbies, interests in your family

What are your expectations and/or hopes for your Joshua's Camp Family Retreat

Your Story: Please share your child's and family journey as much detail as you wish to share

Other Comments: Is there anything else that you would like to share that would enable us to better serve you during your stay

Checking this box, I attest that all the information provided is true and complete to the best of my knowledge

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Joshua's Camp Family Retreat Application

Supporting Families During their Childhood Cancer Journey