Name

First Name

Last Name

Gender

Male

Female

Date of Birth

MM

DD

YYYY

Parent Name

First Name

Last Name

Parent Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Lymphedema: Primary or Secondary?

Primary Lymphedema

Secondary Lymphedema

Areas where lymphedema is present? (Please check all that apply)

Right Upper Extremity

Left Upper Extremity

Right Lower Extremity

Left Lower Extremity

Buttocks

Genitals

Abdomen

Face

Neck

Is there a family history of lymphedema?

No

Yes, mother's side

Yes, father's side

Current lymphedema treatment? (Please check all the apply)

custom daytime compression garment

off the shelf daytime compression garment

custom nighttime garment

short stretch multi layer bandaging (daytime)

short stretch multi layer bandaging (nighttime)

MLD (manual lymphatic drainage)

pneumatic pump

Full Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address (if different than above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

I am submitting this form with all the correct and most accurate information. I understand that my child and/or myself is expected to be compliant with treatment and participate as much as possible in all sessions and activities unless otherwise informed.

Agree

Disagree

I understand that my child's information will be de-identified and possibly used in a study specific to treatment outcomes while at Camp Watchme.

Yes

I have signed the Waiver of Liability/Photo Release (link located at the top of the page). I understand that failure to pay the registration fee will result in an incomplete registration and my spot will not be guaranteed. *

Yes