Refer a Camper

Camper Information

Has the child you are registering been diagnosed with a childhood cancer?*

Yes
No

Does this child live in Vermont?*

Yes
No

Were they treated for cancer in Vermont?*

Yes
No

We are so glad you are excited about camping! At Camp Ta-Kum-Ta (TKT), we feel that camping experiences can change a life. Unfortunately, at this time TKT only accepts registrations for children who have or have had cancer that live in or have been treated in Vermont. But don't worry - there are many oncology camps around the world! The Children's Oncology Camping Association International keeps a list and you can search for an oncology camp near you by following this link: http://www.cocai.org/index.php/cocai-camps/cocai-member-camps If you have follow-up questions or can't seem to find a camp near you, we recommend that you contact the social worker at the institution where you child was treated to inquire about camping opportunities. If you have any follow-up questions for us, please don't hesitate to contact the TKT camp office at 802-372-5863. Happy Camping! Sasha Fisher Program & Events Assistant Camp Ta-Kum-Ta 802-372-5863 (Camp) https://takumta.org/ Vermont's Camp for Children with Cancer

Thank you for your interest in registering your child at Camp Ta-Kum-Ta. Unfortunately, at this time Camp Ta-Kum-Ta accepts registrations for children who have or have had cancer and who live in or have been treated in Vermont. If you are interested in a camp experience for your child, I recommend that you contact the social worker at the institution where your child was treated to inquire about camp opportunities. If you believe you received this message in error please contact the camp office at 802-372-5863

Thank You

Thank you for your interest in Camp Ta-Kum-Ta. Please complete the following Registration Form. This form will allow Camp Ta-Kum-Ta to provide information directly to your family regarding events and programs.

Name

First Last

Date of Birth

Gender Identity

If gender identity not listed above, please include here

Preferred Pronouns

she/her
he/him
they/them
prefer not to answer

If preferred pronouns are not listed above, please include here

Phone

Address

Street Address Address Line 2 City State ZIP Code

Is the child aware of his/her medical condition?

Yes
No

Diagnosis Date

Qualifying Medical Condition:

Parent(s) / Legal Guardian(s)

Parent/Legal Guardian Name

First Last

Relationship

Mother
Father

Parent/Guardian Mailing Address

Same as above

Parent/Guardian Mailing Address

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Home Phone Number

Same as above

Parent/Guardian Home Phone Number

Cell Phone

Email

Primary Language

Parent/Legal Guardian Name

First Last

Relationship

Mother
Father

Parent/Guardian Mailing Address

Same as above

Parent/Guardian Mailing Address

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Home Phone Number

Same as above

Parent/Guardian Home Phone Number

Cell Phone

Email

Primary Language

Name and Date of Birth of Siblings

Physician and Medical Information

Physician Name

Hosiptal/Treatment Facility

Office Phone

Referring Person

Complete if other than parent

Name

First Last

Relationship to Child

Phone

How did you hear about Camp Ta-Kum-Ta?

Referral source email address

Is your child eligible to come to Camp Ta-Kum-Ta (Now or in the Future)?

Camper Information

Thank You

Parent(s) / Legal Guardian(s)

Physician and Medical Information

Referring Person