Camp ReLEAF 2012
Please enclose a recent picture of your child with this application.
I. Child’s Name: Gender: c Female c Male
Age: Birth Date: Race:
Child’s Name to Appear on Nametag (Nickname):
School Child Attends: Grade:
Child’s T-Shirt size: (child sizes) c S c M c L c XL
(adult sizes) c S c M c L c XL
II. Parent/Legal Guardian Name & Relationship:
Street Address:
City: State: Zip Code:
Email Address:
Home Phone: Work Phone :
III. Person to contact in event of an emergency (if parent/guardian cannot be reached):
Name: Relationship to child:
Daytime phone: Evening phone:
IV. The cost of Camp ReLEAF is $35.00 per camper. Please enclose a check made payable to Duke Hospice Bereavement Services with the application. Scholarships are available upon request.
V. Parent/Legal Guardian Permission Statement:
The health history included in this packet is correct so far as I know, and the person herein described has my permission to participate in all prescribed camp activities except as noted. If he/she appears to be ill, I will not send him/her to the Program. I give permission to Camp ReLEAF staff to share the information contained in this package with the volunteer(s) and counselors who will be working with my child.
Parent/Guardian Signature (please specify) Date
Your Child’s Grief History
Please include as many details as possible when answering the following questions. Attach extra pages if necessary. The information will help us to provide the best camp experience for your child.
1. Name of the person who died: Age at death:
Relationship to the child:
Where did this person die? c Home c Hospital c Other
Date of Death: Cause of Death:
2. What was the age of your child when the death occurred:
Was the child present at the time of the death? c Yes c No
Explain circumstances:
3. Did your child attend the funeral/memorial service? c Yes c No
If Yes, what was your child’s reaction to/or comments about the service?
4. Please describe the relationship between the child and the person who died:
5. Has your child received any professional support (i.e., school counselor, peer support group, psychologist, psychiatrist)? c Yes c No
If Yes, is support currently being provided? c Yes c No
6. Have there been any other deaths of loved ones experienced by this child? c Yes c No
If yes, please explain the nature of the relationship with the person(s) who died and the cause of death.
7. Have there been any other changes or stresses in your child’s life (i.e. divorce, illness, relocation, etc.)? Please explain.
Health History
1. Child’s Name:
2. Health History (check those that apply):
c Allergies (food, animals, etc) c Asthma
c Constipation/diarrhea c Convulsions/seizures
c Diabetes c Ear infections
c Emotional problems c Epilepsy
c Fainting c Hearing impairment
c Heart disease c Kidney disease
c Menstrual cramps c Motion sickness
c Nose bleeds c Sickle cell anemia
c Eating Disorders c Vision impairment
c Wears glasses/contact lenses c Sleep disorders
c Medications taken on a regular basis c Other (please specify)
Please explain any “yes” answers to the above questions. Indicate any information that may be useful to camp staff, including the camp nurse. Also indicate any activities to be encouraged or restricted.
3. Immunizations: Year Primary Series Completed Year of Last Booster
- DTP
- Measles
- Mumps
- Oral Polio
- Rubella
- Tetanus shot
- TB Test:
(year given) (result)
Other special needs:
4. I give permission for camp staff to administer prescriptions and/or first aid to my child.
Parent/Guardian Signature (please specify) Date
Camp ReLEAF § Duke Hospice Bereavement Services § Duke HomeCare and Hospice
Release & Consent Form
I, , hereby give permission for my child,
To attend Camp ReLEAF. I understand that the goal of camp is to help facilitate the bereavement process of my child and provide support for him/her in expressing feelings of grief.
CONSENT FOR MEDICAL TREATMENT
In the event that I cannot be reached or be present, I hereby authorize any Duke HomeCare & Hospice registered nurse to execute any and all documents including any necessary consents, agreements and releases in my behalf which might be required by any medical facility to perform any treatment on account of any accident or illness sustained or incurred by my child, , while attending Camp ReLEAF. I understand that in the event emergency hospital treatment is needed my child will be transported to a local hospital emergency department. I understand that I will be responsible for the costs of any medical treatment provided to my child.
I further agree that in consideration of my child attending Camp ReLEAF, I will indemnify and hold harmless the said Camp ReLEAF and Duke HomeCare & Hospice from any legal action sought by or on my behalf of any person on account of any injury or damage sustained or suffered by my child while attending Camp ReLEAF or undergoing medical treatment. I hereby waive any right of legal action by or on behalf of me or my child against Camp ReLEAF and Duke HomeCare & Hospice.
I have read this release and understand all terms.
Parent/Guardian (please specify) Relationship to Child Date
Parent/Guardian (please specify) Relationship to Child Date
Updated: November 16, 2010 Page 1 of 4