A Fun & Safe Place for Grieving Children

CAMP GOOD GRIEF: REGISTRATION FORM

Camp Good Grief is offered free of charge but space is limited, so be sure to register as soon as possible. An information packet will be mailed to each camper approximately one week prior to the date of camp.

RETURN COMPLETED REGISTRATION FORM BY SEPTEMBER 20, 2014 TO:

Camp Good Grief c/o Hospice Advantage 30700 Telegraph Road, Suite 3450 Bingham Farms, MI 48025 Todays Date:

CAMPER INFORMATION
Campers Last Name: Home Address: Is this your first time attending camp? Grade currently attending: First Name: Middle Name:

Name of school:

Date of Birth:

Age:

Sex:

Yes No
How did you learn about Camp Good Grief?

Male Female

PARENT/GUARDIAN CONTACT INFORMATION

Parent/Guardian:

Home Phone:

Cell Phone:

Work Phone:

Parent/Guardian Email:

Employer Phone:

ATTENDING CAMP IN MEMORY OF

Name: Relation to camper: Cause of death: Date of death:

Was the death expected?

Yes No

Was the death unexpected?

Yes No

Please attach a separate sheet of paper to describe any changes in your childs thoughts, feelings, or behaviors that you hav e noticed since the death.

IN CASE OF EMERGENCY
Name of Parent or Guardian: Relationship to Camper: Home Phone: Work Phone:

In the event of an emergency or sickness, I authorize the camp nurse to render necessary first aid. In the event that appropriate treatment cannot be provided at the campsite, I consent for my child to be taken to the Emergency Department where the physician will exercise his or her best judgment as to the diagnosis or treatment and hospital service that may be rendered. I understand that, should the need for medical care arise, I will be financially responsible for all costs incurred in rendering and providing medical attention to my child and neither Hospice Advantage nor Camp Good Grief is obligated to provide insurance or assume financial responsibility for medical assistance provided.

Patient/Guardian Signature

Date

CONSENT
By signing below, I consent the following: I give Hospice Advantage and Camp Good Grief staff permission to photograph, video and/or interview my child and to use these images, recordings, and/or quotes in staff training and in the promotion of camp in the community via brochures, ads, newspaper articles, and other forms of publication.

Patient/Guardian Signature

Date

Please attach a photo of your child for counselor reference or email to pikonen@hospiceadvantage.com