Camp HOPE, Inc. · Camp Hope Registration Form

How many children are registering for the camp?

*

Please tell us about the child who will be camping

Please tell us about the first child who will be camping

Camper Name

*

First Name

Last Name

Camper's age

*

Camper Date of Birth

*

(mm/dd/yyyy)

Child address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Child's county

*

Which camp is the child registering for?

Child's Shirt Size

*

Does the child require transportation assistance?

*

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:

My Child's Pronouns

Select all that apply

She/Her

He/Him

They/They

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.

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

Select all that apply

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic or Latina/o/x

Middle Eastern or North African

Another race/ethnicity not listed

If you selected "another race/ethnicity not listed" for your race/ethnicity please describe:

Tell us about your child

What are your child's hobbies or interests?

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?

Please describe any specific concerns or pertinent information:

*

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

Child's relationship to the person who died

*

Health Information for First Child

Emergency Contact

*

First Name

Last Name

Emergency Contact Phone Number

*

If you're registering more than one child, the emergency contact listed above will be used for all children you register. If the emergency contact will be different for each child, please add the additional emergency contacts (with phone numbers) here:

Any health conditions?

Any allergies we should be aware of?

Any operations or serious injuries that we should be aware of?

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

Immunizations up to date?

*

Date of last Tetanus

Any medically prescribed meal plan or other dietary restrictions?

Gluten free? Vegetarian? No peanuts? Etc....

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

*

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

Tylenol

Ibuprofen

Cough Syrup

Cough Drops

Benadryl Gel

Calamine Lotion

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

*

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.

Is your child currently taking any medication?

Does your child need any medication at camp this weekend?

*

Medication name, dosage, and any special instructions

Please tell us about the second child who will be camping

Name of Second Child Camper

*

First Name

Last Name

Second child camper's age

*

Second Child Camper Date of Birth

*

(mm/dd/yyyy)

This child lives at the same address as the first child

Address for second child

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

County of second child

Which camp is the second child registering for?

Second child's shirt size

*

Does the second child require transportation assistance?

*

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

*

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

My second child camper's pronouns:

Select all that apply

She/Her

He/Him

They/They

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

*

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

Select all that apply

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic or Latina/o/x

Middle Eastern or North African

Another race/ethnicity not listed

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

Tell us about your second child

What are your second child's hobbies or interests?

Please describe for your second child camper any specific difficulty in school or in relationships with others:

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

Please describe any specific concerns or pertinent information for your second child camper:

*

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

Second child's relationship to the person who died

*

Health Information for Second Child

Any health conditions?

Any allergies we should be aware of?

Any operations or serious injuries that we should be aware of?

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

Immunizations up to date?

*

Date of last Tetanus

Any medically prescribed meal plan or other dietary restrictions?

Gluten free? Vegetarian? No peanuts? Etc....

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

*

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

Tylenol

Ibuprofen

Cough Syrup

Cough Drops

Benadryl Gel

Calamine Lotion

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

*

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.

Is your child currently taking any medication?

Does your child need any medication at camp this weekend?

*

Medication name, dosage, and any special instructions

Please tell us about the third child who will be camping

Name of Third Child Camper

*

First Name

Last Name

Third child camper's age

*

Third Child Camper Date of Birth

*

(mm/dd/yyyy)

This child lives at the same address as the first child

Address for third child

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

County for third child

Which camp is the third child registering for?

Third child's shirt size?

*

Does the third child require transportation assistance?

*

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

*

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

My third child camper's pronouns:

Select all that apply

She/Her

He/Him

They/They

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

*

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

Select all that apply

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic or Latina/o/x

Middle Eastern or North African

Another race/ethnicity not listed

If you selected "another race/ethnicity not listed" for your third second child's race/ethnicity please describe:

Tell us about your third child

What are your third child's hobbies or interests?

Please describe for your third child camper any specific difficulty in school or in relationships with others:

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

Please describe any specific concerns or pertinent information for your third child camper:

*

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

Third child's relationship to the person who died

*

Health Information for Third Child

Any health conditions?

Any allergies we should be aware of?

Any operations or serious injuries that we should be aware of?

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

Immunizations up to date?

*

Date of last Tetanus

Any medically prescribed meal plan or other dietary restrictions?

Gluten free? Vegetarian? No peanuts? Etc....

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

*

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

Tylenol

Ibuprofen

Cough Syrup

Cough Drops

Benadryl Gel

Calamine Lotion

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

*

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.

Is your child currently taking any medication?

Does your child need any medication at camp this weekend?

*

Medication name, dosage, and any special instructions

Please tell us about the fourth child who will be camping

If you'd like to register more than 4 children, please reach out to Maria (marialoy@camphopeforkids.org) for a another form.

Name of fourth Child Camper

*

First Name

Last Name

Fourth child camper's age

*

Fourth Child Camper Date of Birth

*

(mm/dd/yyyy)

This child lives at the same address as the first child

Address for fourth child

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

County of fourth child

Which camp is the fourth child registering for?

Fourth child's shirt size

*

Does the fourth child require transportation assistance?

*

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

*

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

My fourth child camper's pronouns:

Select all that apply

She/Her

He/Him

They/They

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

*

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

Select all that apply

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic or Latina/o/x

Middle Eastern or North African

Another race/ethnicity not listed

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

Tell us about your fourth child

What are your fourth child's hobbies or interests?

Please describe for your fourth child camper any specific difficulty in school or in relationships with others:

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

Please describe any specific concerns or pertinent information for your fourth child camper:

*

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

Fourth child's relationship to the person who died

*

Health Information for Fourth Child

Any health conditions?

Any allergies we should be aware of?

Any operations or serious injuries that we should be aware of?

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

Immunizations up to date?

*

Date of last Tetanus

Any medically prescribed meal plan or other dietary restrictions?

Gluten free? Vegetarian? No peanuts? Etc....

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

*

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

Tylenol

Ibuprofen

Cough Syrup

Cough Drops

Benadryl Gel

Calamine Lotion

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

*

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.

Is your child currently taking any medication?

Does your child need any medication at camp this weekend?

*

Medication name, dosage, and any special instructions

Information about the child's deceased loved one

Name and age of person who died

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 the child or children campers live with the person who died?

Please describe changes in your family since the death:

If your child(ren) 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 the relationship your loved one had with each of your children:

*

Anything else you'd like us to know?

We know that some of your responses to our questions may not fit neatly into our pre-filled boxes. Feel free to clarify or add to the information you've given us.

How did you hear about Camp HOPE?

*

Photo Release

*

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.

Signature

*

The primary emphasis of Camp HOPE for adults is to provide an opportunity to share your 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.

Date

*

(mm/dd/yyyy)

Your relationship to child/children

*

Guardian Contact Information

Guardian Name

*

First Name

Last Name

This guardian lives at the same address as the child camper

Your relationship to the camper/campers attending:

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

County

Email

*

*Email is the main source of communication between Parent/Guardian and Camp HOPE.

Verify Email

*

Phone

*

Will you be attending camp?

*

Which camp are you registering for?

My gender or gender identity is best described as:

*

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

My Pronouns

Select all that apply

She/Her

He/Him

They/They

My race or ethnicity identity is best described as:

Select all that apply

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic or Latina/o/x

Middle Eastern or North African

Another race/ethnicity not listed

If you selected "another race/ethnicity not listed" for your race/ethnicity please describe:

Do you have any medical concerns, allergies, or dietary restrictions we should be aware of? If yes, please describe:

Your Shirt Size

*

Please describe your relationship with the person who died:

If you have lost more than one loved one, please add their information here:

Please describe your relationship with your surviving children:

Tell us about yourself.

Anything you'd like to share! Hobbies, personality, etc...

Will there be an additional adult attending camp with the child?

Additional Adult Camper's Contact Information

If more than 2 adults are joining us at Camp, please email Maria (marialoy@camphopeforkids.org) for an additional form.

Additional adult camper name

*

First Name

Last Name

This additional adult camper lives at the same address as the child camper

Address of additional adult camper

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

County of additional adult camper

Email of additional adult camper

*

*Email is the main source of communication between Parent/Guardian and Camp HOPE.

Verify Email

*

Phone of additional adult camper

*

Which camp is this additional adult camper registering for?

Additional adult camper's gender or gender identity is best described as:

*

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

Additional adult camper's pronouns :

Select all that apply

She/Her

He/Him

They/They

Additional adult camper's race or ethnicity identity is best described as:

Select all that apply

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic or Latina/o/x

Middle Eastern or North African

Another race/ethnicity not listed

If you selected "another race/ethnicity not listed" for additional camper's race/ethnicity please describe:

Does this additional adult camper have any medical concerns or allergies we should be aware of? If yes, please describe:

Additional adult camper's shirt size

*

Please describe the second adult's relationship with the person who died:

If the second adult has lost more than one loved one, please add their information here:

Please describe the second adult's relationship with your surviving children:

Tell us about the second adult

Anything you'd like to share! Hobbies, personality, etc...