Camp Form PREVIEW Camp Good Grief Application Name of Child* First Last DOB* MM slash DD slash YYYY Age at Camp*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country First Time Attending*Is this the child’s first time attending Camp Good Grief?YesNoCamp to Attend*Lakeview Park, Port Clinton (July 16th – 18th)Gender*MaleFemaleT-Shirt Size*Youth SmallYouth MediumAdult SmallAdult MediumAdult LargeAdult XLSelect the T-shirt sizeAllergiesDietary RestrictionsBee Sting Reactions*NoYesUnknownParent / Guardian InformationParent / Guardian Name* First Last Relationship to Camper* Parent / Guardian's Phone Number*Parent / Guardian's Alternate Phone NumberParent / Guardian's Email Address Alternate Contact Information An Alternative Contact is an adult authorized to pick-up / drop off child. **Individuals dropping off and picking up children should be prepared to show identification if requested. IN AN EMERGENCY, THE CHILD WILL BE TAKEN TO THE NEAREST HOSPITALAlternate Contact Name First Last Alternate Contact Relationship to Camper Alternate Contact Phone NumberIs there anyone else permitted to pick this child up from camp?Additional Alternate Contact Name First Last Additional Alternate Contact Relationship to Camper Additional Alternate Contact Phone NumberBereavement HistoryName of Deceased First Last Approximate date of death MM slash DD slash YYYY Cause of death Deceased age at death Relationship to child (i.e., parent, grandparent, sibling, etc.) Age of child at the time of the deathPlease enter a number from 0 to 99.Where did this person die (i.e., home, hospital, hospice facility, etc)? Was the child present at the time of the death?YesNoDid the child attend calling hours?YesNoDid the child attend the funeral?YesNoHas your child received professional grief support?YesNoPlease check all that apply to the child's mood/behavior in the past 3 months. anger sadness guilty feelings fear regrets worry anxiety hopelessness loneliness withdrawl nightmares separation anxiety Please describe areas checked aboveIs this child taking any medication related to mood or behavior?YesNoIf yes, please listPlease describe other significant changes/stresses in this child’s life that may come up during his/her time at camp (ex., other deaths including pets, divorce/separation, illness, loss of friendship, parent’s loss of employment, etc.).How does this child get along with other children?What else should we know about your child?Please ask your child what he/she is looking forward to at Camp Good Grief.What are you hoping this child will gain from the camp experience?Are there any medical, social, behavioral or emotional issues we should be aware of?Medication PermissionIs the child taking any medications, if so what medications?Potential side effects of medication(s):Please call me immediately if:I give my permission to Stein Hospice staff at Camp Good Grief to administer my child’s medication(s) as needed during camp.N/AYesNoI give my permission to Stein Hospice staff at Camp Good Grief to observe my child self-administer medication(s) as needed during camp.N/AYesNoSupervision Supervision is only provided during camp hours, not before or after. Camp hours are from 10:00 am to 2:00 pm. The adult dropping the child off must check in with staff and communicate who will pick the child up. At pick up, the authorized adult must sign out the child. If your child demonstrates unsafe or inappropriate behavior at camp, you (or the alternative contact if you can’t be reached) may be contacted to pick up the child. Registration Please submit your registration early to avoid being put on a waiting list. Submit this registration form to Stein Hospice, Attn: Kathy Failor 1200 Sycamore Line Sandusky, Ohio 448702024 Provisions for Pandemic Camps registrations are limited for each camp. First timers to camp will be given priority. Cancelations of camps may occur if the pandemic is unstable at that time, notifications would be given. Masks may be required at camp drop off and pick up and possibly during certain times through-out camp day. Social distancing practices will be encouraged. Parental ConsentI give permission for my child to participate in Camp Good Grief, presented by staff and volunteers of Stein Hospice, an affiliate of Hospice of the Western Reserve. I understand that if the Group Facilitators have, or develop, concerns regarding the appropriateness of my child for this group, those concerns will be communicated to me. If necessary, recommendations or referrals to other counseling professionals will be explored.Parental Consent: Parent Signature (type full name as signature): Photo and Media Release I (the undersigned) hereby grant permission to Stein Hospice and Hospice of the Western Reserve to use my photograph/interview statements/video/story in publicity material and on its World Wide Web site or in other Stein Hospice publication or publications marketing the programs and services of Stein Hospice without further consideration. I acknowledge Hospice's right to crop or treat the content at its discretion. I also acknowledge that Stein Hospice may choose not to use my media materials at this time but may do so at its own discretion at a later date. I also understand that once my content is posted on Stein Hospice’s website, the image can be downloaded by any computer user. Therefore, I agree to indemnify and hold harmless from any claims the following: Board of Directors of Stein Hospice, an affiliate of Hospice of the Western Reserve, Stein Hospice and All Employees and Volunteers of Stein Hospice Stein Hospice reserves the right to discontinue use of media materials without notice.I / we, the undersigned, hereby consent to the use of the name of the individual below by Stein Hospice an affiliate of Hospice of the Western Reserve, Inc., or its designees.YesNoI / we, the undersigned, hereby consent to the making of photographs, motion pictures, videotapes and audiotapes of the person named below by Stein Hospice an affiliate of Hospice of the Western Reserve, Inc., or its designees.YesNoI / we understand that the material will be used for editorial, news, educational and/or promotional purposes to further the goals of Stein Hospice an affiliate of Hospice of the Western Reserve. Material may also be used by other institutions or professional groups for education with authorization from Stein Hospice.YesNoI / we, the undersigned, hereby consent to the use of the name, images and story about the individual below on Stein Hospice an Hospice of the Western Reserve, Inc. online properties including but not limited to the website (hospicewr.org), Facebook (facebook.com/hospicewr), Twitter (twitter.com/hospicewr), YouTube (YouTube.com/HospiceWReserve) and LinkedIn.YesNoName of Individual First Last Enter today's date MM slash DD slash YYYY Photo and Media Release: Parent Signature (type full name as signature): Participant Waiver By signing below, I agree that my child (type name below), may participate in all Camp Good Grief activities at the location and dates below (choose one).Child's Name*Type your child's name. Camp*Lakeview Park, Port Clinton (July 16th – 18th)Acknowledgement I understand that participation in the Program constitutes certain risks, and that injuries may occur. I voluntarily, knowingly, and intelligently recognize and accept any risk and agree to release from liability and to indemnify and hold harmless Stein Hospice/Hospice of the Western Reserve, its agents, assigns, or successors from all liability or claims, demands, damages and costs for or arising out of my participation in the Program whether caused by negligence or otherwise. I have read this waiver and understand all its terms.Date*Select Today's Date MM slash DD slash YYYY Parent / Guardian Name* First Last Type your name as Parent / Guardian signature*