CAMP
JAMIE CHILD APPLICATION
ALL
INFORMATION IS STRICTLY CONFIDENTIAL
Although not all fields are required we ask that you
please fill out as much of this form as possible to
simplify the enrollment process.
|
| |
*
= Required |
| Referral
Source: |
|
| Date
of Camp: |
ex. 01/01/2003 |
| * Child's
Full Name: |
|
| NickName
(if any): |
|
| Child's T-Shirt
size: |
|
| * Home
Address: |
|
| County
in which you reside: |
|
| City: |
|
| * State: |
|
| * Zip: |
|
| * Child's
Age: |
|
| * Child's
Date of Birth: |
ex. 01/01/1990 |
| Gender: |
Male
Female |
| Grade(this
coming September): |
|
| * Parent's/Guardian's
Name: |
|
| * Telephone
Number (Day): |
410-123-1234 |
| Telephone
Number (Evening): |
410-123-1234 |
| |
|
| Siblings |
|
| * Name: |
|
| * Age: |
|
| |
|
| * Name: |
|
| * Age: |
|
| |
|
| * Name: |
|
| * Age: |
|
| |
|
| Has
your child ever spent the night away from home: |
Yes
No |
| Has
your child attended Camp Jamie in the past: |
Yes
No |
| If
so, when: |
|
| Has
your child attended any bereavement camp in the past?: |
Yes
No |
| If
so, when and where: |
|
| |
|
| Emergency
Contact |
|
| * Full
Name: |
|
| Relationship
to Child: |
|
| * Telephone
Number (Day): |
410-123-1234 |
| Telephone
Number (Evening): |
410-123-1234 |
| Telephone
Number (Alternate): |
410-123-1234 |
| |
|
| Bereavement
History |
|
| |
|
| Name
of Person(s) who died: |
|
| Relationship
to deceased: |
|
| Year
of death: |
ex 1995 Age:
|
| Cause
of death: |
|
| Was
your child present at the time of death: |
|
| Explain
circumstances: |
|
| Did
your child attend the funeral/memorial service: |
yes
no |
| If
no, why not: |
|
| Please
explain how your child indicates that he/she is still grieving: |
|
| Has
your child received any professional support i.e. psychologist,
psychiatrist, school counselor, support group) and how
ong was the professional support provided: |
|
| Has
your child experienced any other deaths? Please explain: |
|
| Have
there been any other changes/stresses in your child's life
(i.e. divorce, illness, relocation, etc.) Please explain: |
|
| |
|
| Behavior/Physical/Medical |
|
| |
|
| Please
check those that apply: |
Sleep Disorders (i.e. sleeping walking, bed wetting )
|
|
Eating Disorders |
|
Poor School Attendance |
|
Poor Grades |
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Lack of Social Skills |
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Difficulty getting along with Peers |
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Difficulty getting along with Adults |
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Difficulty getting along with Family |
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Behaviour Problems |
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Physical Limitations
|
|
Allergies
|
|
Asthma
|
|
Dietary Restrictions |
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Convulsions/Seizures |
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Diabetes |
|
Ear Infections |
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Hearing Impairment |
|
Nosebleeds |
|
Motion Sickness |
|
Wears Contact/Glasses
|
|
Medications taken on a regular basis. |
|
Other |
| |
|
| Please
explain any items that were checked or indicate any other
useful information regarding your child's health: |
|
| |
|
**
If any medication will be required, a physician’s
order form will need to be completed and returned prior
to your child attending camp. Forms will be available at
the Hospice Office. ** |
