Camp Kesem Camper Application

Name______

December 1st, 2011
Dear Friend,
Thank you for your interest in Camp Kesem, a camp for children who have a parent who has died from cancer, is currently in treatment for cancer, or is in remission from cancer. Camp Kesem will take place from August 19th – August 24th at Camp Merrowvista in Tuftonboro, New Hampshire. Campers should be dropped off at Merrwovista on August 19th, and transportation from Camp back to the MIT campus will be provided on August 24th.
The mission of Camp Kesem is to provide a student-run summer camp program for children who have or had a parent with cancer, where campers build self-esteem and gain support from peers facing similar challenges. With a camper-counselor ratio of 2:1, campers receive the special attention and support that they would not receive at a regular summer camp.
55 volunteer counselors from MIT will staff the camp and will undergo extensive training prior to camp. The professional staff will include a Nurse, a Psychotherapist, and a Camp Advisor.
Camp Kesem is open to all children in the New England area, between the ages of 6 and 18, regardless of race, religion, color, national origin, or financial status. Due to the financial burden experienced by families coping with cancer, Camp Kesem is provided free of charge to all families.
Camp Kesem will accept 80 children this year: 60 regular campers, and 20 campers in our Teen Program. Applicants will be accepted on a first-come, first-serve basis, with consideration to ensure appropriate balances of age and gender. THE APPLICATION DEADLINE IS April 30th. If your child would like to attend Camp Kesem, please return the enclosed application to the address below as soon as possible. We will notify you when we have received your child’s application. Be sure to fill out a separate application for each child you wish to send to camp. If you have further questions, please do not hesitate to contact us at .
Sincerely,
Evan Moore and Angela Ma
Camper Care Coordinators

Camp Kesem Camper Application

General Information

Date: ____/____/____

**Please attach a recent photo of your child here.

Child Information
Full Name: / Nickname:
Date of Birth: / T-Shirt Size : Youth Small Youth Medium Youth Large
Adult Small Adult Medium Adult Large Adult XLarge
Age as of first day of Camp: / Sex: MALE FEMALE
Height: ______feet and ______inches Weight: ______pounds
Current Address:
City: / State: Zip: / Email:
Parent / Guardian Information
Parent / Guardian Name:
Relationship to Child:
Address:
City: / State: / Zip:
Home Phone: ( ) / Work Phone:( )
Mobile Phone: ( ) / Email:
Native Language:
Parent / Guardian Name:
Relationship to Child:
Address:
City: / State: / Zip:
Home Phone: ( ) / Work Phone: ( )
Mobile Phone:( ) / Email:
What is the best way to contact you? Please circle: Home Phone Mobile Phone Work Phone Email
When is the best time of day to contact you?
Native Language:
If one/both parent’s native language is not English:
Would you like to receive subsequent camp documents translated in your native language?
Yes No
Your child’s native language:
If your child’s native language is not English:
Would you like to receive camp documents translated in your child’s native language?
Yes No
If child does not live with both parents, who has legal custody?
Please explain the custody arrangements.
Siblings
Name: / Age:
Name: / Age:
Name: / Age:
Emergency Contacts (Please provide two contacts.)
At least one emergency contact must be in local area during the week of camp.
Name: / Relationship:
Work Phone: / Home Phone:
Name: / Relationship:
Work Phone: ( ) / Home Phone: ( )
Additional Information
Has your child been away from home before? Yes No
If yes, please describe:
Please provide the name of the parent who has/had cancer, the date he/she was diagnosed, and what the diagnosis and prognosis are:
How much does your child know about the parent’s illness? Are there any specific ways that you help your child cope with the parent’s illness?
How did you hear about Camp Kesem? Please be specific.
Has your child attended Camp Kesem before? Yes No
If no, would you like to be contacted by a member of the Camp Kesem Parent Committee?
Yes No
If yes, would you like to join the Camp Kesem Parent Committee, which serves to offer support for and answer questions from new parents?
Yes No
Transportation:
Would you be willing and able to carpool with another Camp Kesem family to/from camp?
Yes No
If yes, how many spots would you have available in your vehicle? _____ # of spots
Optional Sweatshirt Order:
Size : Youth Small Youth Medium Youth Large
Adult Small Adult Medium Adult Large Adult XLarge / Sweatshirts will be available for pickup during camper pickup on the last day, August 24th.

Camp Kesem

Parent/Guardian Questionnaire

Date
Parent/Guardian Name
Camper Name
Number of years your child has attended Camp Kesem : ___ years
As we aim to promote a positive camp experience, we request that parents/guardians assist us by completing this questionnaire. Your answers to the following questions will help us to understand and prepare for your child. We greatly appreciate your cooperation and time.
1. Give a brief description of your child (such as personality, attitudes, habits, etc.).
2. Have there been any recent major changes in your child’s life such as a move, a death, separation, or birth of a sibling?
3. Please describe your child’s exposure to cancer in your family and how he/she has dealt with the situation. How has your child reacted to this? How is child currently reacting? What is helpful and not helpful to the child?
4. What level of understanding does your child have about their parent’s cancer or death?
5. What kinds of people does your child tend to get along with best? Are there any types of people that your child tends to avoid?
6. Does your child have any friends who have a parent who has cancer, had cancer, or has died from cancer? If so, how many?
7. How does your child feel about being away from home?
8. Does your child have any learning challenges, physical disabilities, or developmental, social, or emotional issues? Please explain.
9. How does your child feel about coming to Camp Kesem?

Thank you for taking the time to complete this questionnaire!

A Letter to My Camp Counselor

Dear Counselor,

My name is ______, and my friends call me

______. I am in _____ grade. I have

___ sisters and ___ brothers. The thing I am most excited about

doing at camp is ______!

My secret worry about camp is that ______

______. I am coming to Camp

Kesem because ______.

If I could bring one thing to camp with me, it would be ______

______, because ______

______. Outside of school,

(check each one that applies to you)

___I play an instrument or sing. What instrument?______

___I play a sport. What sport? ______

I like (circle which ones you like) art swimming acting

playing with friends other______

This is how I feel about school: (you can circle more than one)

happy scared sad angry

Tell us why:______

This is how I feel about home: Tell us why:

happy scared sad angry

This is how I feel about being away from home:

happy scared sad angry

Tell us why:______

What I like about my best friends is that ______.

I have (circle one) MANY (more than 10) SOME (5-9) A FEW (1-4) ZERO

friends who have a parent who has cancer, had cancer, or died from

cancer.

This is how I feel about hanging out with kids who know what it’s like to

have a parent who has cancer or has died from cancer:

happy scared sad angry

Tell us why:______

This is how I feel about Camp Kesem: Why?______

happy scared sad angry

______

See you soon!!!

(sign your name here)

Rev. 7/11 Camp Kesem MIT. 617.848.2824. .

Camp Kesem at MIT is an affiliate of Camp Kesem National,