Dear Campers and Families

Dear Family Campers,

We look forward to having you and your child(ren) participate in Camp Phoenix, Saturday, May 2 from 8:30am to 5:00 pm. Thiswill be a fun and worthwhile experience for your family.

For each family member attending, please complete the enclosed forms (Registration Forms and Medical History) and return it byApril 24, 2009. We must have all of these forms completely filled outfor your family to attend camp. A $10.00 deposit is required to assure your reservation and should be sent in with these forms. The deposit will be refunded to you when your family arrives at camp. A list of what your family should and should not bring to camp is also enclosed. Pleasebringpictures of your loved one to share during grief activities.

OnSaturday, May 2, please plan to arrive at KaryaePark(which is where CampPhoenix is held) by 8:30 p.m. Directions are enclosed for your convenience. This is a family event, so plan to attend with your child. The camp will end at 5:00 pm.

Please call the New HopeCounselingCenter at (704) 861-8405 or email me if you have any questions or need further information.

Sincerely,

Adrian Thornburg, MA, LPC

CampPhoenix Coordinator

CAMPPHOENIX CHILD REGISTRATION

Camper’s Name: ______

Date of Birth: ______Age: ______T-shirt Size ______

School: ______Grade: ______

Referred by: Self, TV, Hospice Flyer, School Counselor, other______

PARENT INFORMATION

*The participation of at least one parent or legal guardian at camp is required.

Parent/Guardian: ______

Address: ______

Home Phone: ______Work Phone: ______

Cell: ______Email: ______

Do both parents live in the home? Yes No

If not, please provide the following contact information:

Parent/Guardian Name: ______

Mailing Address: ______

Home Phone: ______Work Phone: ______

Cell: ______Email: ______

Name & Relationship of deceased person to child ______

Was deceased a Gaston Hospice patient? Yes No Give name:______

Did camper live with the deceased? Yes No

Date of death: ______Age at death: ______

Type of Death: ( )Accident ( )Long term illness ( )Short term illness ( )Traumatic

(Murder/Suicide)

Was camper present at death: Yes No

Since the Death, what changes have you seen? (Check items)

()School Problems ()Nightmares ()Friends (fighting/withdrawal)

()Increase in fears ()Expresses desire to die/kill self ()Emotional struggles

(crying/confusion/guilt/bedwetting)

()Physical Symptoms (sleeping more/less, appetite, physical complaints) ()none

() Other symptoms ______

List other current stressors or significant losses for the child over the last 2 years

(ex: Divorce, loss of a pet, move, etc.) ______

______

Has your child/teen been in any support groups or counseling? ______If yes, please explain:

______

Additional Information, Interests or Special Abilities: ______

______

I grant permission for photographs/slide show, written evaluation comments, or interviews with my child to be used for educational purposes and/or to promote future camps. I release Gaston Hospice and the GastonCountyYMCA and its affiliates from any claim or liability for that use.

Yes No

______

Parent/Guardian Signature Date

______

Parent/Guardian Signature Date

Children’s Medical Information

MEDICAL INFORMATION

Primary Care Phyisican: ______

Phone number: ______

List any physical or mental concerns your child may have. ______

Are there any activities that should be restricted? ______

List any allergies that we should know about (ex: Food, Hay Fever, Insect Stings, Medications, Asthma, Latex, etc.):

Date of last immunizations: ______Tetanus: ______

AUTHORIZATION FOR TREATMENT:

I hereby give permission to camp personnel to release medical history information, to contact the primary care physician, and/or to provide or arrange related transportation for my child in case of emergency to the nearest medical facility. In the event I am unable to give permission or be reached in an emergency, I hereby give permission to camp personnel to secure and administer treatment, including hospitalization for my child. I understand that no accident or medical insurance is provided and agree that I will be financially responsible for medical treatment received.

Signature of Parent or Guardian______

Date ______

I give my permission for my child, ______, to participate in the team building and ropes course activities as provided by the staff of the YMCA of GastonCounty while attending CampPhoenix atKaryeaPark YMCA Outdoor Facility.

YES NO

I understand that the New HopeCounselingCenter for Grief and Loss, Gaston Hospice, Inc., Caromont Health, CampPhoenix, Gaston YMCA, camp staff/volunteers will not be held liable in case of personal accident and/or injury, illness, or property loss or damage.

Parent/Guardian Signature______Date ______

Informed Consent for CampPhoenix

Gaston Hospice

*The goal for children attending CampPhoenixis to leave with a better understanding of what grief is and how to use their personal coping skills.

*CampPhoenixis a structured environment that will assist with grieving emotions that present themselves in children when a close family member dies. Although there will be fun, games, and music at the camp, there will also be counseling groupsstructured for campers to explore their own personal emotions and the grieving process. Most people chose counseling with hopes of feeling better. However, as with any powerful intervention, there are both benefits and risks associated with counseling. Risks might include experiencing uncomfortable feelings like sadness, anxiety, anger, guilt, or frustration. It is not uncommon for children/adolescents/adults to report feeling worse after the first few sessions. It is our goal to support the entire family as they sort through these feelings and guide them toward more self-direction in their life (an identified benefit of counseling).

*Client information is confidential in regards to other agencies or persons. However, North Carolina state law requires exceptions to this rule in the case of: a) suspected child abuse, b) suspected elder abuse, c) suspected domestic violence, d) stated intention to injure another person, e) imminent danger of harming oneself, f) subpoena from a court of law. In these situations, the appropriate agency or persons will be notified.

Symptoms to Look for After Camp

Sleep disturbancesFatigue (related to grief work)

HeadachesAngerDreams

StomachachesFearPreoccupation

WithdrawalReliefConfusion

AnxietySadnessVerbal attacks

CryingExtreme QuietnessNightmares

What to Do?

Continue with open communication with child.

Let the child know that you are prepared to talk with them when they are ready.

Don’t force the child to talk before he/she is ready.

Call the counselors at Gaston Hospice with any concerns. We are available to any child or family who attends camp by calling 704-861-8405.

I have read the above and understand the goals, benefits, and risks of CampPhoenix.

______

Parent Signature Date

______

Witness Signature Date

Parent Copy

Informed Consent for CampPhoenix

Gaston Hospice

*The goal for children attending CampPhoenixis to leave with a better understanding of what grief is and how to use their personal coping skills.

Symptoms to Look for After Camp

Sleep disturbancesFatigue (related to grief work)

HeadachesAngerDreams

StomachachesFearPreoccupation

WithdrawalReliefConfusion

AnxietySadnessVerbal attacks

CryingExtreme QuietnessNightmares

What to Do?

Continue with open communication with child.

Let the child know that you are prepared to talk with them when they are ready.

Don’t force the child to talk before he/she is ready.

Call the counselors at Gaston Hospice with any concerns. We are available to any child or family who attends camp by calling 704-861-8405.

CampPhoenix Adult Registration

Name: ______

T-shirt Size: ______

Address: ______City/State______Zip______

Home Phone: ______Work Phone: ______

Email: ______

Name and Relationship of deceased loved one:______

If spouse, please circle: Married Separated Divorced

Other significant losses in your life: ______

Changes I have seen in myself since the death:

Who is a part of your current support system? ______

Are you currently involved in a grief support program? YES NO

If yes, name of program and where it is held: ______

What do you expect to get from this camp experience? ______

My greatest concern is ______

Permission

I grant permission for photographs/slide show written evaluation comments, or interviews of me to be used for educational purposes and/or promote future camps. Furthermore, I release the Gaston Hospice and the GastonCountyYMCAfrom any claim or liability for that use.

______

Signature Date

Adult Medical Information

CampPhoenix

Name: ______

First Last

DOB: ______Age: ______

List any physical concerns you may have. ______

Are there any activities that should be restricted? ______

Any health problems, allergies, medications: ______

______

IN CASE OF EMERGENCY, THE CAMP SHOULD NOTIFY

Name: ______Phone: ______

Relationship: ______

Secondary party to notify in case we cannot reach the person listed above:

Name: ______Phone: ______

Relationship: ______

Primary Physician: ______Phone: ______

Name of Practice: ______

AUTHORIZATION FOR TREATMENT:

I hereby give permission to the camp medical personnel to release medical history information, to contact the primary care physician, and/or to provide or arrange related transportation in case of emergency to the nearest medical facility. I hereby give permission to the camp medical personnel to secure and administer treatment, including hospitalization for me. I understand that no accident or medical insurance is provided and agree that I will be financially responsible for medical treatment received.

Signature ______Date ______

CampPhoenix

Directions to KaryeaPark

YMCA Outdoor FamilyCenter

Gastonia, NC

Location: 4227 South Linwood Rd., Gastonia, NC28052.

From Downtown Gastonia, take Franklin Blvd-US 74 to South Linwood Road approximately 5 miles. The OutdoorCenter will be on your left before Camp Rotary Road.

You can MapQuest this at using your home address.

What to Bring to Camp

Tennis Shoes must be worn at camp at all times.

(You may want to bring an extra pair)

Dress for the weather/Rain Gear

Pictures of deceased love one for a project that can be cut, taped

or glued

Camera (optional)

Picnic Basket of food to feed

your family for Lunch

DO NOT BRING RADIOS, CD PLAYERS,

HAND HELD VIDEO GAMES, CELL PHONES, SANDALS OR FLIPFLOPS