Camper Information

Please complete this encrypted and secure form for each child attending camp.

About the Camper
Camper's First Name*
Last Name*
Age*
Gender
Height & Weight
Health History
HEALTH HISTORY [Check all that apply]

Attention Deficit DisorderAsthmaEar InfectionFaintingWears GlassesAcquired Immune Deficiency SyndromeConstipation/DiarrheaFears/PhobiasHepatitisKidney DiseaseMenstrual CrampsDevelopmentally DelayedNosebleedsEmotional ProblemsConvulsions/SeizuresDiabetesHearing ImpairmentADHDAllergiesMotion SicknessHeart DiseaseWears ContactsHIVSickle Cell AnemiaNightmaresSpecial Dietary NeedsOther (please explain)
Please explain information we may need to know to care safely for your child.
Medications child may need to take at camp
Food Allergies (please provide severity of food allergies, reactions and any other information)
Drug Allergies (please provide severity of allergies, reactions and any other information)
Pet or animal dander allergies (please provide of allergies, reactions and any other information)
Other significant allergies
Please list any dietary restrictions (physician recommended/religious, etc.)
Are there any activities your child may not be able to participate in while at camp?*

NoYes (please explain)
Have there been any other changes or stressful situations in your child’s life such as divorce, illness, recent move, multiple losses, etc.? Please describe.
Has your child experienced any behavioral problems you believe may be related to the death?*

NoYes (please explain)

Does your child have difficulty with any of the following areas? If yes, please explain.

	Check if yes	Please explain
Sleeping?
Eating?
School?
Relationships?

Are there any language, disability, or other needs, family customs, or cultural aspects to your child’s grieving that we should be aware of?
What are some ways your child expresses their grief or emotions related to their loss? (Ex: acting out, increased clinginess, questions about the death or avoiding discussion)
Are there any specific concerns or challenges your child is currently facing in their grief journey that you would like our team to be aware of?
Is there anything else you would like us to know about your child’s personality, preferences, or comfort needs to help us support them best during camp?
Is your child currently receiving counseling? If so, please explain the primary purpose.
About the Deceased
Name of the deceased*
Age of person who died*
Relationship to camper*
Date death occured

MonthDayYear
Age of camper at time of loss*
Cause of death*
Briefly describe the relationship between the camper and the deceased
Did the camper reside with the person who died?*

YesNo
Did the camper witness the death?*

YesNo
Was the camper present at the funeral/memorial?

YesNo
Is there anything specific that you feel would be helpful for our team to know relating to the death and your child?
Authorizations and Permissions

Parent/Guardian: Please read all authorizations and permissions required and provide your signature where indicated. Your authorization must be granted in order for your child to attend camp.
I hereby authorize Angela Hospice Home Care, Inc., and its staff to supervise and instruct my child in all Camp Monarch program activities. I am aware of the nature of the Camp Monarch activities and any brochure, flyer or announcement relating to such activities is expressly incorporated by reference into this document. I hereby give my unqualified permission for my child to participate in all camp activities, for which he or she may qualify under camp standards. I am aware that there are inherent risks in camp activities and particularly in situations that involve physical activity, there may be a risk of injury. I understand that Angela Hospice does not provide accident or health care insurance for my child and that I am responsible for this insurance. I understand that it is my responsibility to inform Angela Hospice of any and all physical limitations, liabilities or injuries involving my child, including without limitation, neck and back problems, recent surgery, allergies and any other medical situations.*

Yes
In the event of emergency, I hereby authorize the staff of Angela Hospice to administer first aid and/or obtain emergency medical treatment [911] as determined by Angela Hospice staff, including as necessary transportation for such treatment. This treatment may include routine tests and x-rays. I understand that in the event of an injury or other medical problem, Angela Hospice staff shall make every effort to notify me or a person I have identified as an alternate contact person as soon as possible and, subject to the need in a particular circumstance, to make an immediate decision regarding any such first aid and/or emergency medical treatment. Angela Hospice staff shall refer all non-emergent decisions relating to the medical care of my child to me or my alternate contact person.*

Yes
I understand that Angela Hospice shall not be responsible or liable for the loss of personal property or any consequence of personal injury sustained by my child. This includes, but is not limited to, personal injury or loss of personal property sustained while participating in off-site activities. I hereby do indemnify and hold harmless Angela Hospice Home Care, Inc., from any loss, claim, or expense [including attorney’s fees] incurred by Camp Monarch but not caused by its negligence, arising from the personal injury of or loss of personal property by my child during Camp Monarch.*

Yes
I hereby grant to Angela Hospice Home Care, Inc., and its legal representatives the right and unrestricted permission to use and publish photographs or video images of my child from this event, or in which my child may be included, for any purpose authorized by Angela Hospice Home Care, Inc., including but not limited to: website use, editorial publications, broadcast media (radio, television), literature and advertising use. This grant includes the right to modify and retouch the images in the discretion of Angela Hospice Home Care, Inc., I understand that the circulation of such materials could be worldwide and there will be no compensation to me for this use. I understand that I will not be given the opportunity to inspect or approve the finished products or the advertising copy or the printed matter that may be used in connection therewith.*

YesNo
PERMISSION FOR GRIEF COUNSELOR
M.S.W. grief counselors will be present to provide supportive services to the Camp participants. Except for emergency evaluations, parents or guardians need to provide consent in order for counselors to intervene with their child. By signing below, you are providing your consent for your child to speak with a grief counselor if he/she desires. This is not a “counseling session” or an “assessment” but it is intended to enhance the camp experience for your child. The counselors will be supportive listeners and provide an opportunity for your child to talk about his/her life experiences. If a mental health emergency were to arise, these counselors will be available to assess
the campers and advise camp personnel.
Parent/Guardian Signature*

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Camper Information

About the Camper

Health History

About the Deceased

Authorizations and Permissions

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