BASE Camp - New Family Registration
BASE Camp Children's Cancer Foundation has programs all year long: a monthly overnight camp, food pantry, meals for families in the hospitals and clinics, Milestone Parties (cakes and balloons), parent support, FREE tickets to various events and more. Sign up below to become eligible for all BASE Camp programs and to join the family!

BASE Camp is proud to be able to help you along this journey. We truly hope that BASE Camp programs bring you joy and encouragement to finish the climb!

Patient First Name: *
Your answer
Patient Last Name: *
Your answer
Date Of Birth: *
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Gender: *
What county does the patient reside in?
Diagnosis:
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Date of Original Diagnosis:
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Treatment Facility: *
Treating Physician: *
Name of Mother/Guardian *
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Name of Father/Guardian *
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Parent/Guardian Contact - Phone *
Your answer
Parent/Guardian Contact - Email *
Your answer
Parent/Guardian Contact - Address Line 1 *
Your answer
Parent/Guardian Contact - Address Line 2 *
Your answer
May we share your information with other organizations who may be able to assist your family? *
Photo Release: I/We give permission for our child/children's photo to be used by BASE Camp Children's Cancer Foundation. *
These photographs are commonly used on the BASE Camp social media pages, website, press releases, as well as sponsor thank you letters.
Does the patient have any siblings? *
Patient siblings are eligible to be part of BASE Camp programs as well!
How many siblings?
Your answer
Sibling (1) Name
Your answer
Sibling (1) Birthday
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Sibling (2) Name
Your answer
Sibling (2) Birthday
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Sibling (3) Name
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Sibling (3) Birthday
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Sibling (4) Name
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Sibling (4) Birthday
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Other Siblings Information:
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