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2023 Next Step Fall Campference

Name: 2023 Next Step Fall Campference
Start: 2023-10-20T00:00:00-04:00
End: 2023-10-22T23:59:59-04:00

October 20 - October 22

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We are hosting our annual Fall Campference for young adults living with chronic illness from Friday, October 20 to Sunday, October 22 at the Warren Conference Center and Inn in Ashland, MA. This FREE Next Step Campference is open to young people, ages 18-29.

Part camp, part conference, our 3-day Fall Campference fosters friendships and community with peers who “get it.” At a Next Step Campference, you can:

Engage in educational workshops
Recharge with new friends
Join the music and art mayhem
Create fun, life-changing moments
Empower yourself with information and resources

Sounds good?! Spots for our Fall Campference program fill up fast so we encourage you to submit your application below as soon as possible to secure your spot!

In Their Words

Our participants say it best. Read stories from young people who have attended a Next Step Campference.

Do you have questions before signing up?

Email Casey Casey, Next Step Nursing Director & Partnership Coordinator, at casey@nextstepnet.org or Kepler Jeudy, Next Step Program Director, at kepler@nextstepnet.org if you have any questions about our Fall Campference for young people living with chronic illness.

2023 Fall Campference Application

Please fill out this application if you are interested in joining our 2023 Next Step Fall Campference.

The Next Step Fall Campference is for young adults, ages 18-29, and will be held in Ashland, MA at the Warren Conference Center & Inn.*
- Friday, October 20 to Sunday, October 22
The Next Step Fall Campference is for young adults, ages 18-29, and will be held in Ashland, MA at the Warren Conference Center & Inn.
Have you been on a Next Step Campference before?*
- Yes
- No
How did you hear about the Next Step campference?*
- Website
- Another Participant
- Medical Staff
- Other
If medical staff, please include name, position and hospital:*
Name*
First Last
Nickname
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Alternate Phone
Email*
Preferred mode of contact?*
- Email
- Cell Phone (Call)
- Cell Phone (Text)
Current Occupation
Employer or School
Age
Birthday
MM slash DD slash YYYY
Gender
T-shirt size
Hospital or Clinic where you receive medical care?
What do you hope to get out of the Next Step campference experience?
What topic(s) do you most want to learn about at Campference?
PARENT/GUARDIAN AND EMERGENCY CONTACT
Name*
First Last
Relationship
Phone
Email
Medical Overview
Diagnosis
Date of Diagnosis
MM slash DD slash YYYY
Are you on active Treatment?
- Yes
- No
Food Allergies & Reactions
Environmental Allergies (bee, latex, etc) & Reactions
Do you carry an Epi-Pen?
- Yes
- No
Are there are any special accommodations you would need (dietary, mobility, equipment, etc.)? Please explain:
Are there any activity limitations?
Please list any medications you take, and how often.
Please take a moment to describe what symptoms you display if you’ve overextended yourself or are starting to get sick. How can we best support you in such a situation?
INSURANCE INFORMATION
(Please bring your insurance card to the program)
Insurance Co:
Policy #:
Name of Insured:
First Last
Prescription
Plan #:
Telephone #:
Over the Counter Medications: I—or my child, if under the age of 18—has permission to take over-the-counter medication, for the dosage amount suggested by the pharmaceutical maker, if feeling unwell due to symptoms such as headache or stomachache. Please check appropriate boxes and provide your signature below:
I—or my child, if under the age of 18—may take over-the-counter medication that I brought:*
- Yes
- No
I—or my child, if under the age of 18—may take OTC medication provided by a staff person:*
- Yes
- No
I—or my child, if under the age of 18—should not, under any circumstances, be given the following OTC medications:
Please indicate:*
- I consent
- I do not consent
CONSENT AGREEMENT
AUTHORIZATION AND RELEASE This Consent Agreement, Authorization and Release must be read and signed to be eligible to attend Next Step's Young Adult Campference. RELEASE OF LIABILITY I understand that occasionally accidents occur during campference activities and that participants may sustain serious personal injury and property damages as a consequence thereof. Knowing the risks of campference activities, nevertheless, and in consideration of my acceptance for participation at a campference, I hereby agree to assume those risks and to hold harmless Next Step, and all campference agents, representatives, employees and volunteers, from any and all liability, claims for personal injury and/or property damage, costs, expenses and damages arising out of or connected in any way with my participation in campference activities. Further, I acknowledge that Next Step accepts no responsibility for the loss, damage or theft of my personal property. I acknowledge and understand there is an increased risk that Covid-19 and other communicable illnesses can be transmitted in any public place, including an in person Next Step program. Next Step seeks to protect its staff and participants during any and all in person activities. By attending a Next Step in person program, I agree to assume these risks. Additionally, as a precondition to participating in a Next Step program I understand to participate in person I must be up to date on my vaccinations against Covid-19, Measles, Mumps, Rubella, Varicella, and Pertussis (unless medically exempt with a doctor's note). I must also have my provider complete a medical application every 12 months to participate in person at a Next Step program.
Please indicate:*
- I consent
- I do not consent
CONSENT FOR MEDICAL TREATMENT
The undersigned hereby grants permission to the medical staff or consulting physicians at Next Step to administer medication and provide medical care for me, including any medical emergency care required. I also give my consent for any emergency transportation deemed necessary.
Please indicate:*
- I consent
- I do not consent
Community Agreement/Rules of Conduct
The young adult campference is a close-knit community; therefore we ask that you agree to a few things that will promote being together in a safe manner. Please sign this Community Agreement, which asks that you agree to conduct yourself ethically and respectfully while living in the program:*
- 1. Delegates are to demonstrate a high degree of maturity and self-respect, taking into account the rights and feelings of others.
- 2. Delegates are responsible for charges incurred, e.g. vandalism and breakage of property, etc.
- 3. Delegates are to adhere to curfews, directives and designated schedule times.
- 4. Suitable attire is to be worn during the campference workshops and activities.
- 5. Smoking is prohibited indoors.
Please select as an indication that you will adhere to the code of conduct.
The Following Behaviors are grounds for Immediate Dismissal:*
- 1. Physical confrontations or assaults. This means harming, attempting to harm, or threatening to harm another person, with or without a weapon or dangerous object
- 2. Bullying. As defined as unwanted, aggressive behavior that involves a real or perceived power imbalance. The behavior is repeated, or has the potential to be repeated, over time. Verbal bullying is saying or writing mean things. Social bullying involves hurting someone’s reputation or relationships and can include leaving someone out on purpose, telling other’s not to be friends with an individual, spreading rumors, embarrassing someone.
- 3. Stealing or damaging property
- 4. Possession or use of drugs and alcohol
- 5. Sexual misconduct or sexual assault
- 6. Leaving without permission
- 7. The possession of any type of weapon
Please select as an indication that you understand the behaviors that are unacceptable at the program.
Please indicate:*
- I agree to the community agreement
- I do not agree to the community agreement
PHOTO AND INFORMATION RELEASE
I give Next Step permission to photograph and use pictures or visual and/or audiotapes of me in professional or fundraising activities. On occasion, with this permission, participant photographs may be included on the Next Step website, on a bulletin board, video, newsletter, campference album, or in personal photographs. Next Step respects the privacy of participants and does not allow unauthorized visitors to photograph the campference or participants. In addition, by signing below, I give Next Step permission to give my name, address and/or phone number to groups or individuals wishing to support Next Step by inviting me to an event or by sending me information related to Next Step. This list will not be sold or given to anyone else for any other reason.
Please check appropriate box and provide your signature below:*
- I agree to the photo release
- I do not agree to the photo release
Please Sign
By signing below, I hereby acknowledge that I have read and fully understand the terms and expectations of the program. All information provided is current and accurate to the best of my knowledge.
Name*
First Last
Date*
MM slash DD slash YYYY
Please check this box to indicate that the above signature will serve as your electronic signature
- (Delegate or Legal Guardian if the Delegate is not over the age of 18)

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Details

Start:: October 20
End:: October 22
Event Categories:: Cancer, HIV, Program, Rare Genetic Disorder, Sickle Cell
Event Tags:: Chronic Illness, Fall Campference, free program, Next Step Campference, Warren Conference Center & Inn, Young Adults

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2023 Next Step Fall Campference