Camp Genesis 2019 Application
Camp Genesis is a specialty residential (sleep-away) camp experience for children & teens (entering grades 4-9) affected by cancer in their family. A collaborative camp partnership with Gilda’s Club Quad Cities, Camp Shalom and Genesis Cancer Care Institute.

Please note, this is an application form for your child/children to be considered to attend Camp Genesis 2019. Application deadline is set for April 18th. Priority will be given to first-time campers, those with a loved one in active treatment and allotted cabin availability. A selection committee will determine camper eligibility and families will be notified by the week of April 22nd, 2019. Once selected, a registration packet will be sent along with the link to complete the required forms.

For more information please visit http://www.gildasclubqc.org/camp.

For additional questions, please contact Kelly Craft, Program Manager, at Gilda’s Club Quad Cities at (563) 326-7504 or email kcraft@gildasclubqc.org.

FAMILY INFORMATION
Parent/Guardian Name: *
Your answer
Home Mailing Address: *
Your answer
City, State, Zip Code: *
Your answer
Email Address: *
Your answer
Home Phone: *
Your answer
Cell Phone:
Your answer
Please note which immediate household member has been directly affected by cancer: *
Your answer
Please indicate how long it has been since the family member's last treatment for cancer: *
Your answer
CAMPER 1 INFORMATION
CAMPER 1: First and Last Name *
Your answer
CAMPER 1: Grade Entering in Fall 2019 *
CAMPER 1: T-Shirt Size *
Your answer
CAMPER 1: Is this your camper's first time for camp with Gilda's Club? *
CAMPER 2 INFORMATION
CAMPER 2: First and Last Name
Your answer
CAMPER 2: Grade Entering in Fall 2019
CAMPER 2: T-Shirt Size
Your answer
CAMPER 2: Is this your camper's first time for camp with Gilda's Club?
CAMPER 3 INFORMATION
CAMPER 3: First and Last Name
Your answer
CAMPER 3: Grade Entering in Fall 2019
CAMPER 3: T-Shirt Size
Your answer
CAMPER 3: Is this your camper's first time for camp with Gilda's Club?
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