Camp HOPE, Inc. · Youth/Child Registration Form

Contact Information

Child's Name

*

First Name

Last Name

Guardian's Name

*

First Name

Last Name

Email

Verify Email

Phone

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

County

Is this your address, your child's address, or the address you both reside in?

Which camp are you registering for?

*

Please note, winter camp is only for campers who have previously attended a fall or spring camp.

How did you hear about Camp HOPE?

Transportation Assistance Needed?

*

Yes

No

Possibly

Camper Information

Child's Age

Child's Date of Birth

*

(mm/dd/yyyy)

My child's gender or gender identity is best described as:

If you selected "Another gender not listed" for your child's gender or gender identity, please describe:

Child's Pronouns

Select all that apply

She/Her

He/Him

They/Them

My child's race or ethnicity identity is best described as:

Select all the apply

American Indian or Alaska Native

Asian

Black or African American

White

Hispanic or Latina/o/x

Native Hawaiian or Other Pacific Islander

Middle Eastern or North African

Another race/ethnicity not listed

If you selected "Another race/ethnicity not listed" for your child's race/ethnicity, please describe:

What are your child's hobbies or interests?

Tell us about your child.

Are they shy, outgoing, loving, caring, kind, love to be around people, overwhelmed by loud noises, etc? What do you love about your child? What do they excel at? What do they struggle with?

Names and ages of child's living siblings

Camper's T-Shirt Size

*

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

Adult XXL

Adult 3XL

Camp is striving to be gender inclusive. Would you prefer your child to stay in a cabin with:

*We will do our best to accommodate this request. Please know that if we do not have enough campers who select this option in your age group we will be reaching out to make an individual plan to support your child’s safety and wellbeing. This option is meant to provide safety for our children who may feel unsafe in a gendered cabin, not necessarily for children who would like to sleep cabins with their siblings. If this is a concern for you, please reach out to Maria to talk through options.

Information About the Person Who Died

Name of person who died

*

First Name

Last Name

Age of person who died

Relationship of the person who died

*

If needed - any additional information regarding relationship

Step-parent, foster parent, teacher, family friend, etc...

Date and cause of death

*

**Please be sure the camper is aware of the actual cause of death, as it will be shared at camp.**

Did child live with the person who died?

Please describe their relationship

If your child has lost more than one loved one, please add their information here:

Name, age, relationship to child, date of death, and how the person died

Please describe any specific concerns or pertinent information

*

behaviors, remarriage, aggression, anxiety, sleep issues, mental health concerns, suicidal thoughts, hospitalizations, etc.

Please describe any specific difficulty in school or in relationships with others

What support groups or counseling (if any) has your child been involved in?

I have read, understand, and agree to abide by the operating policy of Camp HOPE

The primary emphasis of Camp HOPE is to provide an opportunity to share experiences, make connections with others who have experienced similar losses, learn coping strategies and above all relax and enjoy nature. Camp HOPE and the programs presented are not intended to be used as a substitute for physician or psychiatric care. Participants understand that by enrolling they are agreeing to take part in the retreat voluntarily and remain responsible for their own physical and emotional choices. By signing this registration you are agreeing to release and hold harmless Camp HOPE and its representatives from any and all liability. All information is confidential.

Guardian's Signature

*

Relationship to Child

*

Date

*

(mm/dd/yyyy)

Authorization to Disclose Camper Photos and Videos

I authorize Camp HOPE to release my camper’s image and likeness taken during the Camp HOPE program. The purpose of this disclosure is to promote the program, and/or fundraise for Camp HOPE. The image and/or likeness can also be used for Camp HOPE’s marketing efforts, including, but not limited to, a brochure or video promoting Camp HOPE, or other educational programs or fundraising events for Camp HOPE. Right to Revoke: I understand that I have the right to revoke this Authorization at any time by giving Camp HOPE written notice of the revocation. I understand that any revocation will not apply to any disclosure that has already been made in reliance upon this Authorization. I understand that I have the right to refuse the use of my camper’s image and likeness below and that my refusal will not affect my child’s experience. I understand that I may request a copy of this signed Authorization. A copy of this document is valid as an original. The original is not required to be shown. The Authorization will expire on December 31, 2033.

*

I authorize the disclosure of photos of my camper(s)

I DO NOT authorize the disclosure of photos of my camper(s)

Camper Health History Form

This form is required and is to be filled in by parent/guardian

Child Name

*

First Name

Last Name

Birth Date

*

(mm/dd/yyyy)

Parent/Guardian Name

*

First Name

Last Name

Person who died

*

Emergency Contact Name

*

First Name

Last Name

Emergency Contact Phone

*

I give my child permission to receive emergency medical care

*

Yes

No

Health Conditions

*

Please check all that apply

Frequent ear infections

Heart Defect/Disease

Asthma

Diabetes

Hepatitis

HIV

None

Other

Additional information/treatment on any of the above or other chronic or recurrent conditions

Allergies

*

Please check all that apply

Insect stings

Food

Hay fever/sinus

Poison Ivy

Medication

None

Other

Additional information/treatment on any of the above allergies

Any medically prescribed meal plan or dietary restrictions?

*

Any operations or serious injuries?

*

Please include dates

Immunizations up to date?

*

Date of last Tetanus

*

(mm/dd/yyyy)

Has your child received mental health treatment? If yes, please explain.

*

Physician

*

First Name

Last Name

Physician's Phone

*

If applicable, who is your insurance provider and group number?

*

Please notify Camp HOPE if this camper is exposed to any communicable disease during the three weeks prior to camp attendance. Please advise if the camper is on medication for any communicable disease.

*

I understand that I must notify Camp HOPE if this camper is exposed to any communicable disease during the three weeks prior to camp attendance.

Parent/Guardian Signature

*

This health history is correct and I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine tests, treatment and necessary transportation for me/my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization for me/my child. *MUST be completed for Attendance*

Date

*

(mm/dd/yyyy)

Medication Information

May the Health Staff administer over the counter pain medication if needed?

*

**Please note: Parent/guardian will be contacted for any major medical concern that occurs at camp. Be sure we have a phone number to be able to reach you this weekend.

Yes

No

My child can be given the following over the counter medication:

*

Tylenol

Ibuprofen

None

Health Staff will administer Epipen (>66 pounds) or Epipen JR (<66 pounds) for a major allergic reaction. Benadryl will be given for minor and major allergic reactions. Any comment?

Benadryl Gel or Calamine Lotion will be used for itchy skin or bug bites. Any comment?

Is your child currently taking any medication?

*

Yes

No

Does your child need any medication at camp this weekend?

*

All prescription medications must be brought to camp in their original, properly labeled containers. The container should have the correct number of pills for this weekend only. Any changes from those on the container must be verified in writing by a physician. Be sure the expiration date is current.

Yes

No

Medication name, dosage, and any special instructions

All medication will be administered by health office staff. Campers will not be allowed to have medication in their cabins. Inhalers may be self-administered with parent/guardian permission.