General Information
Child's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Please Select
Male
Female
Prefer not to answer
Child's Age
*
Parent/Legal Guardian's Full Name
*
Realtionship to Child
*
Parent/Legal Guardian's Email Address
*
Parent/Guardian's Phone Number
*
Emergency Contact #1 (Name & Phone Number)
*
Emergency Contact #2 (Name & Phone Number)
*
If your child is not allowed to have contact with certain people/persons, please list their names and relationship to child below.
Your child will receive a free T-shirt. Please select the appropriate size for your child
*
Please Select
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
Has your child attended Camp SMILE previously?
*
Please Select
Yes
No
Unsure
How did you hear about Camp Smile?
*
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Grief History
Relationship of deceased to child
*
Please Select
Mother
Father
Sibling
Friend
Relative
Other
Was the deceased affiliated with St. Claire Hospice?
*
Please Select
Yes
No
Unsure
Date of Death
*
-
Month
-
Day
Year
Date
Cause of Death
*
Does your child know the cause of death?
*
Please Select
Yes
No
Unsure
Where did the death occur?
*
Was your child present at the time of death?
*
Please Select
Yes
No
Unsure
Did your child witness the death?
*
Please Select
Yes
No
Unsure
Does your child have a spiritual belief about where their lost loved one is now?
*
Please Select
Yes
No
Unsure
If yes, please explain
If you answered "Yes" to the previous question, please explain your child's belief
Was the service a burial or cremation?
*
Please Select
Burial
Cremation
Other
Did your child attend the funeral?
*
Please Select
Yes
No
Unsure
Has your child received any professional support?
*
Please Select
Yes
No
Unsure
If you answered "Yes" to the previous question, please select all forms of professional support that apply
Counselor
Hospice Bereavement Care
Minister
Psychiatrist
Psychologist
School Counselor
None of the above
Other
What other losses has your child experienced in their lifetime? (Check all that apply)
*
Death of a parent
Death of a sibling
Death of a friend
Death of a relative
Death of other significant person
Loss of home
Separation from sibling(s)
None of the above
Other
Please select any of the following grief reactions that your child is currently experiencing. (Check all that apply)
*
Change in appetite
Difficulty sleeping
Uninterested in activities that they previously enjoyed
Irritable
Guilty feelings
Suicidal thoughts/behaviors
Getting into fights with peers and/or family
Avoids talking about loved one
School grades have declined
Withdrawing from friends and family
Having flashbacks about events or loved one
Cries easily
Increased dependency on caregivers
Nightmares
New onset of anxiety
Have there been any other changes or stresses in your child's life (divorce, remarriage, relocation, illness)? If so, please list date.
Has your child ever spent the night away from home?
Please Select
Yes
No
Unsure
Does your child have any sleep problems (sleepwalking, bedwetting, nightmares)? If so, please list below
Please explain how your child indicates that he/she is still greiving?
*
Please list some of your child's hobbies and interests (to help match the camper to a volunteer).
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Health History
Does your child have any health concerns?
*
Please Select
Yes
No
If yes, please explain
Is your child on any medications?
*
Please Select
Yes
No
If yes, please list
Does your child have any physical injuries?
*
Please Select
Yes
No
If yes, please describe injuries
Does your child have allergies to any of the following: foods, animals/insects, medicines, trees, plants, other
*
Please Select
Yes
No
Unsure
If yes, please list allergies
Insurance Information
Please provide your camper's insurance information below. This information is needed in case a medical emergency occurs.
Name of Insurance Carrier
*
ID#
*
Policy Holder
*
Claims # (on back of card)
*
Name of child's family doctor
*
Family doctor phone number
*
Submit
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