2022 Camp Wieser Application Step 1 of 10 10% Camp Wieser 2022 A Program of the Me-One Foundation Camp Dates - September 16, 17 and 18 PLEASE NOTE: For the purpose of this application, the applicant is the adult (18 or older) currently undergoing treatment for cancer. The camping experience is intended for the applicant and up to five additional guests. These guests can be members of the applicant's family, close friends, and/or caregivers. This year, Camp Wieser will be held on September 16, 17 and 18 at Mission Springs Conference Center in Scotts Valley, California. Approved campers will be extended an invitation to join us at camp provided they can show proof of COVID vaccination and booster history. Please read the COVID-19 Policy HERE before continuing. In addition, a signed approval form from your physician is required. Please print the Physician's Release form and get it to your physician as soon as possible. All transportation costs and travel arrangements to and from Camp Wieser are the responsibility of the camper and their guests. Campers will be directed to arrive at Camp Wieser at approximately 3:00 pm on September 16 where they and their guests will go to the COVID checkpoint for verification of a negative COVID test. COVID-19 testing will occur on Saturday and Sunday as well. Camp will adjourn at approximately 1:00 pm on Sunday, September 18. Space is limited. Camp can accommodate 15 families. This camp session is primarily geared toward adults who are currently undergoing cancer treatment and are physically able to attend camp. Priority is given to first-time campers. Recipients of a 2020 or 2021 Camp Wieser Staycation DO qualify to apply for this in-person camp. Returning campers will be placed on a waiting list. Please note that submitting an application does not ensure an invitation. All completed applications will be reviewed and considered by our selection committee. Selection of applicants for each camp session is solely within the discretion of the selection committee. ALL INFORMATION IS CONFIDENTIAL This is a multi-page form. At the bottom of each page, you can click to Save and Continue Later. So, before you start, have handy this information for each of your guests and yourself: Date of birth T Shirt Size Immunizations Date of last tetanus booster Street and email addresses Phone number Allergies and meds Need help? Write down this name and email. At any time, feel free to reach out while you are working on your application. Erika Reethof, Camper Liaison Erika@nullme-onefoundation.org ******************************************************************************* IMPORTANT: Everyone attending Camp Wieser must have been vaccinated and boosted against COVID-19. All Camper families, all volunteers, all staff, all vendors must show proof of vaccination. If your application is approved and you accept the invitation to attend Camp Wieser, we will send you instructions on how to provide proof of COVID-19 vaccination/booster history for yourself and your guests.I can attest to the fact that I and all my guests have been fully vaccinated and boosted against COVID-19*YesI will print the Physician's Release Form and get it to my physician.*A completed Physician's Release Form is required to attend camp. If you are not able to print the Physician's Release form referenced above, send an email to erika@nullme-onefoundation.org requesting one. It's ok to click "no" here but do get the release form in process!YesNoBesides myself, I plan to bring this many guests (up to 5 guests)*Please enter a number from 0 to 5.Would this be your first time at an in-person Camp Wieser?*Preference is given to applicants who have never attended an in-person Camp Wieser. YesNoMy primary email (one I check frequently)*Email is the Foundation's primary communication method. Please provide your main email address. Enter Email Confirm Email About MeMy Name* First Last My Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code My Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920My Primary Phone*My Secondary PhoneMy Primary Email Address*Email is the Foundation's primary communication method. Please provide your main email address in this field. Enter Email Confirm Email My Secondary Email AddressIf you have another email address which you check regularly (daily) enter it here. Enter Email Confirm Email Have you attended a Me-One Foundation Camp as a Camper before?*NoYesMy T-Shirt Size*Adult SmallAdult MediumAdult LargeAdult X LargeAdult 2X LargeAdult 3X LargeMy Immunizations - Check all that apply Select All Have had H1/N1 flu shot Have had measles vaccination Have had chicken pox or vaccine My Last Tetanus Booster DateI would like to receive Me-One Email updates after CampYesNo Please tell us about this guestGuest #1* First Last Guest #1 Relationship to You*Is Guest #1's street address the same as the Applicant's street address?*YesNoGuest #1 Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Guest #1 Email Address Guest #1 Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Guest #1 Mobile PhoneGuest #1 T-Shirt Size*None SelectedChild Extra SmallChild SmallChild MediumChild LargeAdult SmallAdult MediumAdult LargeAdult X LargeAdult 2X LargeAdult 3X LargeGuest #1 Immunizations - Check all that apply Select All Has had H1/N1 flu shot Has had measles vaccination Has had chicken pox or vaccine Guest #1 Date of Last Tetanus BoosterGuest #1 Allergies and Meds and Medical ConditionsPlease list all allergies, medications, and or medical conditions we should be made aware of in order to best support this guest at Camp.Please indicate whether Guest #1 would like to receive Me-One email updates after camp.YesNo Please tell us about this guestGuest #2Guest #2* First Last Guest #2 Relationship to You*Is Guest #2's street address the same as the Applicant's street address?*YesNoGuest #2 Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Guest #2 Email Address Guest #2 Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Guest #2 Mobile PhoneGuest #2 T-Shirt Size*None SelectedChild Extra SmallChild SmallChild MediumChild LargeAdult SmallAdult MediumAdult LargeAdult X LargeAdult 2X LargeAdult 3X LargeGuest #2 Immunizations - Check all that apply Select All Has had H1/N1 flu shot Has had measles vaccination Has had chicken pox or vaccine Guest #2 Date of Last Tetanus BoosterGuest #2 Allergies and Meds and Medical ConditionsPlease list all allergies, medications, and or medical conditions we should be made aware of in order to best support this guest at Camp.Please indicate whether Guest #2 would like to receive Me-One email updates after camp.YesNo Please tell us about this guestGuest #3Guest #3* First Last Guest #3 Relationship to You*Is Guest #3's street address the same as the Applicant's street address?*YesNoGuest #3 Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Guest #3 Email Address Guest #3 Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Guest #3 Mobile PhoneGuest #3 T-Shirt Size*None SelectedChild Extra SmallChild SmallChild MediumChild LargeAdult SmallAdult MediumAdult LargeAdult X LargeAdult 2X LargeAdult 3X LargeGuest #3 Immunizations - Check all that apply Select All Has had H1/N1 flu shot Has had measles vaccination Has had chicken pox or vaccine Guest #3 Date of Last Tetanus BoosterGuest #3 Allergies and Meds and Medical ConditionsPlease list all allergies, medications, and or medical conditions we should be made aware of in order to best support this guest at Camp.Please indicate whether Guest #3 would like to receive Me-One email updates after camp.YesNo Please tell us about this guestGuest #4* First Last Guest #4 Relationship to You*Is Guest #4's street address the same as the Applicant's street address?*YesNoGuest #4 Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Guest #4 Email Address Guest #4 Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Guest #4 Mobile PhoneGuest #4 T-Shirt Size*None SelectedChild Extra SmallChild SmallChild MediumChild LargeAdult SmallAdult MediumAdult LargeAdult X LargeAdult 2X LargeAdult 3X LargeGuest #4 Immunizations - Check all that apply Select All Has had H1/N1 flu shot Has had measles vaccination Has had chicken pox or vaccine Guest #4 Date of Last Tetanus BoosterGuest #4 Allergies and Meds and Medical ConditionsPlease list all allergies, medications, and or medical conditions we should be made aware of in order to best support this guest at Camp.Please indicate whether Guest #4 would like to receive Me-One email updates after camp.YesNo Please tell us about this guestGuest #5* First Last Guest #5 Relationship to You*Is Guest #5's street address the same as the Applicant's street address?*YesNoGuest #5 Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Guest #5 Email Address Guest #5 Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Guest #5 Mobile PhoneGuest #5 T-Shirt Size*None SelectedChild Extra SmallChild SmallChild MediumChild LargeAdult SmallAdult MediumAdult LargeAdult X LargeAdult 2X LargeAdult 3X LargeGuest #5 Immunizations - Check all that apply Select All Has had H1/N1 flu shot Has had measles vaccination Has had chicken pox or vaccine Guest #5 Date of Last Tetanus BoosterGuest #5 Allergies and Meds and Medical ConditionsPlease list all allergies, medications, and or medical conditions we should be made aware of in order to best support this guest at Camp.Please indicate whether Guest #5 would like to receive Me-One email updates after camp.YesNo More about youThe information on this page is for the Camp Directors and Medical Staff and is treated in a confidential manner and stored on a secure server. It will enable us to plan for your needs at Camp. Patients/Campers will be responsible for administration of all routine medications and treatments themselves. All medications and other supplies must be brought with the Camper. If the Camper needs IV therapy or other pre-known medical treatments during camp, this can be considered and perhaps accommodated with prior communication through the Me-One Foundation's Camp Medical Team on site.DiagnosisGrade or StageDate of DiagnosisTreatment CenterPhysicianPhysician PhoneIs there a central venous access device (Hickman, Groshong, Port-A-Cath) and if so which type?Are you or your family able to care for line access independently?How often do you flush the line?What kind of dressing is used?Have there been any recent problems with the line?Are you receiving any cancer-directed treatment at this time?*YesNoDate of last chemotherapy/treatmentName of most recent chemotherapy/treatmentIs there a post-chemo/treatment symptom control regimen, and what does it entail?Please clearly explain your current condition and history with cancer. For instance, include if you are in remission and if so, for how long. What is the prognosis? Please include any other information you deem important to help us clearly understand your condition and history. Just a few more questions...bear with us!How were you referred to Camp Wieser and/or the Me‐One Foundation (name of social worker or nurse navigator, for example)?*Your Allergies and Meds and Medical Conditions*Please list all allergies, medications, and or other medical conditions we should be made aware of in order to best support you at Camp.Do you or your guests have mobility problems or require a wheelchair? Mission Springs is not ADA compliant (yet) and even first floor rooms have a single step at the entrance. Upper floor rooms are accessed via stairs. We will try our best to accommodate you but cannot guarantee easy access for all.Do you or any other members of your family require a special diet? We will do all we can to meet your needs. However, in some cases, you may be asked to bring your own special food if we are unable to provide.Is there anything else you feel we should know and/or that we could do to make your experience at camp safer or more meaningful? Anything else you care to share? RELEASE, WAIVER OF LIABILITY, MEDICAL AUTHORIZATION & PHOTO RELEASE TO BE ACCEPTED BY APPLICANT ON BEHALF OF THEMSELVES AND THEIR GUESTS The applicant on behalf of him/herself, their agents, heirs and representatives hereby releases, waives, discharges and covenants not to sue Camp Wieser, Me‐One Foundation or any of its affiliates, members of its Board of Directors, employees, agents, contractors, volunteers and all other camp personnel whether volunteers or paid staff, (hereinafter referred to as “Releasee(s))” for any and all liability, claims, demands, damages, causes of action, losses, or expenses (including attorney’s fees and expenses) to the undersigned and/or to any minor child being signed for, on account of physical, mental, or emotional injury, an outbreak of any and all communicable disease, including but not limited to, the virus “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)”, which is responsible for Coronavirus Disease (COVID-19) and/or any mutation or variation thereof, or death of the person or minor child or to the property of the person or minor child, whether such injury or death be caused by the negligence, gross negligence of the Releasee(s) or otherwise, while the person or minor child participates in Camp. Notwithstanding any other provision of this Release and Waiver, the undersigned also releases Me-One Foundation, but no other Releasee from any liability whatsoever arising from any injury, damage, or death to the person or minor child where said injury, damage, or death is the result of, or arises from any intentional or criminal conduct upon the part of a Me-One employee, agent, volunteer, camp counselor, or any other camp personnel. The applicant grants permission for the Me‐One Foundation affiliated medical volunteers to treat and act upon any and all medical conditions as deemed appropriate by them. The undersigned hereby releases, waives, discharges and covenants not to sue Camp nor the Me‐One Foundation or any of its affiliates, members of its Board of Directors, employees, agents, contractors, volunteers and all other camp personnel whether volunteers or paid staff for any and all liability, claims, demands, damages, causes of action, losses, or expenses (including attorney’s fees and expenses) to the undersigned and/or to any minor child being signed for. The applicant hereby grants Camp Wieser and/or the Me‐One Foundation or any of its affiliates, members of its Board of Directors, employees, agents, contractors, volunteers, guests and all other camp personnel, whether volunteers or paid staff, permission to allow, take, release or utilize pictures and/or recordings of an audio or visual nature or both of themselves and/or any minor they are signing for, as deemed appropriate by Camp Wieser and/or the Me‐One Foundation for means of public relations, marketing, media or otherwise. The applicant further expressly agrees that the foregoing release and waiver is intended to be as broad and inclusive as is permitted by the law of the State of California, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effort. The applicant has read and voluntarily signs the Release and Waiver of Liability and Photo Release and further agrees that no oral representations, statement or inducement apart from the foregoing have been made, and that this Agreement may only be modified by a written document signed by the applicant and a duly authorized representative of the Me‐One Foundation. Revised 23 June 2022 Agree to Release*I agree to the statement aboveI do not agree to the statement aboveI have read and understand the COVID-19 Policy and if invited to camp, will fully comply.*YesCongratulations on completing your application for Camp Wieser. Now that your application is in our hands, our selection committee will review it, along with your Physician's Release form which you have provided to your doctor. You'll be hearing from the Camper Liaison shortly! Expect a phone call or at least an email. Click Submit and you are done!In order to complete your application, you need to accept the terms of the release.
