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Camper Application Request
To receive an application to attend Camp Fiesta the camper must be medically insured and between the ages of 7-17. Please complete the following information:
Camper
*
Indicates required field
Name
*
Gender
*
Age as of July 24, 2020
*
Grade as of July 24, 2020
*
Address
*
State
*
City
*
Zip Code
*
Parent/Guardian
Name
*
Home Phone
*
Email
*
Cell Phone
*
Pediatrician or Oncologist
Name
*
Date of Diagnosis
*
Primary Treatment Center
*
Phone Number
*
Date of Remission - if applicable
*
Medical Insurance
*
Submit
Home
Multimedia
Summer Photos
Application Request
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Board of Directors
Contact Us