Become A Base Camp Family New Patient Family Form Patient First Name* Patient Last Name* Patient Date of Birth* Gender* -None-MaleFemale Patient Diagnosis* Date Of Diagnosis* Treatment Hospital* -None-Arnold Palmer HospitalFlorida HospitalNemours Children's HospitalOther Treating Physician* Allergies* Emergency Contact* Relationship* Emergency Contact Number* Mailing Street* Mailing City* Mailing State* Mailing Zip* County* -None-OrangeBrevardVolusiaOsceolaSeminoleLakeFlaglerSumterOther Contact Email* Email Opt Out I authorize photo release for my children & family Guardian Name* Guardian 1 Relationship* -None-MotherFatherGrandparentAuntUncleOther Guardian 2 Name Guardian 2 Relationship -None-MotherFatherGrandparentAuntUncleOther Sibling 1 Name Sibling 1 Date of Birth Sibling 2 Name Sibling 2 Date of Birth Single 3 Name Sibling 3 Date of Birth Sibling 4 Name Sibling 4 Date of Birth Special chaperone or allergy notes for siblings Additional Household Members