STATE OF THE HEART CARE

Camp Encourage Application

Dear Parent or Guardian,

Please complete the following application and medical record form with the understanding that your child is not accepted in the Camp Encourage program until we receive this completed form at the State of the Heart Care office and you receive an acknowledgement letter from our office.

As the parent or guardian of ______, I hereby give my permission for my child to participate in the supervised camping program of State of the Heart Care. I release the Camp staff, management, said Camp, and State of the Heart Care from liability, except covered by insurance, for any injury or illness which may be sustained by him/her while enrolled and present at the Camp. In case of medical emergency, my child will be transported to Mercer Health. After every reasonable effort has been made to contact parent, guardian, family physician or one of the alternative contacts named below, I hereby give my permission to the receiving facility to secure appropriate and proper medical treatment for my child, named above.

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Print Parent or Guardian Name

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Parent or Guardian SignatureDate

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Address, City, State & ZipPhone Number

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Email Address*

Personal/Medical Record

Name of Camper: ______

Home Address: ______City: ______

State: ______Zip Code: ______

Date of Birth: ______Age: ______Sex: Male or Female

School Attending: ______Grade: ______

Please list your child’s religious affiliation, if any (Optional): ______

Has your child ever spent the night away from home? YesNo

Does your child have any sleep problems (e.g. sleepwalking, bedwetting, nightmares, etc…)? ______

______

Please indicate your child’s shirt size:

Youth:Small (6-8) ____ Medium (10-12) ____ Large (14-16) ____

Adult: Small ____ Medium ____ Large ____ X-Large ____

Telephone number, pager/cell phone number and/or address of where you can be reached while your child is at

Camp? ______

Please provide two (2) alternative contacts that you authorize to act on your behalf in case you cannot be reached in an emergency.

Contact 1

Name: ______Phone: ______

Address: ______City: ______State: ____

Contact 2

Name: ______Phone: ______

Address: ______City: ______State: ____

Family Physician: ______Phone: ______

Preferred Hospital: ______Phone: ______

Health Insurance Provider and ID#: ______

Date of Last Tetanus Shot: ______

Does this child have any known physical, mental or social difficulties for which special consideration may be given at Camp?

______

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Health History (check all that apply)

____ADD/ADHD____Constipation/Diarrhea____Hearing Impairment

____HIV/AIDS____Ear Infections____Hepatitis

____Emotional Problems____Motion Sickness____Kidney Disease

____Autism____Diabetes____Menstrual Cramps

____Asthma____Fears/Phobias____Sickle Cell Anemia

____Allergies (food, animals, insect bites or stings)____Fainting____Developmentally Delayed

____Convulsions/Seizures____Heart Disease____Nightmares/Night Terrors

____Nosebleeds____Glasses/Corrective Lenses____Other______

*As a courtesy to other campers, please do not send your child to camp if he/she has a fever or other communicable disease (lice, poison ivy, scabies, ringworm, etc…) that can be transmitted to others or is of extreme discomfort to your child.

Please explain any information we need to know to care safely for your child: ______

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Does your child have any special dietary needs? Please indicate what they are: ______

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BEREAVEMENT HISTORY

Name of loved one who died: ______

Date of Death: ______Relationship to Child: ______

Cause of Death: ______

Where did the person die?_____Home_____Hospital_____Nursing Home

Explain Circumstances: ______

Did the child attend the funeral/memorial service? _____Yes_____No

Other changes/stresses in the child’s life?

  1. _____ Divorce or separation
  2. _____Moving
  3. _____Friend Moving
  4. _____Other Deaths? If yes, who? ______
  5. _____Pet Death
  6. _____Parent changing job/loss of job
  7. _____Other trauma ______

How did the child handle these changes? ______

______

Please explain how your child indicates he/she is grieving: ______

______

Has the child received professional support? (Psychiatrist, psychologist, pastoral or school counselor) Explain:

______

______

Has your child attended Camp Encourage or other grief camps in the past?_____Yes*_____No

*If yes, has your child experienced an additional loss since last attendance to camp?_____Yes_____No

Please identify present behaviors at home or school:

____Less Interactions____Bed wetting____Changes in sleep

____Emotional Outbursts____Changes in appetite____Nightmares

____Dropping Grades____Fear of dark____Inability to concentrate

____Cries frequently

*Camp Encourage is completely funded by grants and donations. Many of the grant issuers require this information to help with the process. Below, you will find four (4) questions, these questions are optional, and all answers will be kept confidential. Thank you for your participation.

Race/Ethnicity:____White/Caucasian____Black/ African American____Hispanic/Latino

____Asian____Native Hawaiian/Pacific Islander____Other:______

Income Level:____less than $15,000____$15,001 - $25,000____$25,001 - $35,000

____$35,001 - $50,000____$50,001 +

Household Family Size: ______

Child’s Living Situation:____Single-Parent (Mother)____Single-Parent (Father)____Two Parent Home

____Grandparent(s)____Other Relative____Guardian

Parent or Guardian Statement

I give permission to State of the Heart Hospice to have pictures taken at Camp Encourage which may be used

for publication.____Yes____No

I believe all of the answers to the questions above are true and that my child is in good health and is able to participate in all the normal activities of Camp Encourage.

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Sign NamePrint Name

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Date

Please return the completed application to:

State of the Heart Care

C/O Camp Encourage

1350 N. Broadway

Greenville, Ohio 45331

Questions may be directed to our Camp Director at 800.417.7535 ext.422.