Family Camp Weekend 2017: Aplastic Anemia and Bone Marrow Failure

Pre-Registration Survey

Thank you for your interest in our 2017 Aplastic Anemia and Bone Marrow Failure Family Weekend. This family weekend will be held October 20 to 22nd at The Hole in the Wall Gang Camp located in Ashford, Connecticut. This camp is provided free of charge. By completing this survey you are simply expressing your interest in the camp. A representative from the camp will follow up with you within the next week or so, providing additional information and application instructions.

IMPORTANT NOTE: Participants in this camp must live in the Northeast Region of the U.S. and reside in PA, NJ, NY, RI, MA, ME, NH, or VT.

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* 1. Parent Name and Address

Parent Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 2. Patient's disease type? (check all that apply)

Aplastic Anemia

MDS

PNH

JMML

MPNs

AML

PRCA

Other (please specify)

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* 3. Patient's First Name

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* 4. Patient's Age (as of October 1, 2017)

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* 5. How many other siblings or family members are likely to attend?

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* 6. Are there any other questions you have?

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* 7. Confidentiality Statement:
I understand that the information provided in this survey will be kept confidential and will be used exclusively to support my family's involvement in this Family Camp. This information will be viewed by AAMDSIF program staff and shared with relevant program staff at The Hole in the Wall Gang Camp. I understand that my information will not be shared with any other organization or entity.

I understand and agree to the terms of the confidentiality statement

I do not agree with the terms of the confidentiality statement (please explain below)