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Camp Healing Hearts


To register by mail, please print and complete this form.

* PLEASE COMPLETE ALL FIELDS *
Children attending

Name:
Age:
School grade:

Name:
Age:
School grade:

Name:
Age:
School grade:


Name of Parent(s) or Guardian(s):


Street Address:
City: State: Zip:

Day phone: Evening phone: Cell:
Email:
Will an adult accompany child to camp?
Yes No
Emergency Contact:

Name of person who died:

Relation to child:
Date of death:
How did your loved one die?



Medical Information
Child's Physician
Physician Phone
Hospital of Choice
Health Care Plan
Effective Date/Group Plan Number
Medications taken on a regular basis? Yes No

If yes, please list all medications here:


Does your child have any of the following conditions?

Allergies Yes No
Child's Name
Explain:


Asthma Yes No
Child's Name
Explain:


Convulsions/Seizures Yes No
Child's Name
Explain:


Diabetes Yes No
Child's Name
Explain:


Changes in Appetite Yes No
Child's Name
Explain:


Dietary Restrictions Yes No
Child's Name
Explain:


Eating Disorders Yes No
Child's Name
Explain:


Ear Infections Yes No
Child's Name
Explain:


Hearing Impairments Yes No
Child's Name
Explain:


Motion Sickness Yes No
Child's Name
Explain:


Nosebleeds Yes No
Child's Name
Explain:


Physical Limitations Yes No
Child's Name
Explain:


Sleep Problems Yes No
Child's Name
Explain:


Visual Impairments Yes No
Child's Name
Explain:


Other Yes No
Child's Name
Explain:


Behavioral Information

Behavioral Problems Yes No
Child's Name
Explain:


Difficulty getting along with other kids Yes No
Child's Name
Explain:


Difficulty getting along with family members Yes No
Child's Name
Explain:


Difficulty getting along with other adults Yes No
Child's Name
Explain:


Poor School Attendance Yes No
Child's Name
Explain:


School Grades Dropped Yes No
Child's Name
Explain:


Other ConcernsYes No
Child's Name
Explain:


T-Shirt Sizes for Child

Child's Name
Age
Size

Child's Name
Age
Size

Child's Name
Age
Size

Child's Name
Age
Size

If Adult attending, please identify size:

T-Shirt Size for Adult 1

T-Shirt Size for Adult 2



We wish to attend:
Mt. Lebanon Camp, Oct. 6, 2012

Indemnification Agreement

1. I, , hereby give permission for my child, , to attend Camp Healing Hearts specified on the attached application. I understand that the camp's goal is to help facilitate the bereavement process of my child and provide support for him/her in expressing feelings of grief.
2. I give permission for my child to be photographed, videotaped or interview during Camp Healing Hearts while under staff supervision. This material may be used for future publicity of Camp Healing Hearts including the news media. Yes No
3. In consideration of the above-named child being granted permission to attend Camp Healing Hearts,

I, for myself and on behalf of my child, release and discharge Camp Healing Hearts, its agents, Board of Directors, Officers, Volunteers, from all claims, demands, actions and judgments, which I or my child ever had or now has or may have against Camp Healing Hearts for all personal injuries, either physical or emotional, know or unknown, and injury to property, real or personal, sustained by my child's person or property during his or her negligence or any other fallout.
4. Also, in consideration of the above-named child being granted permission by Camp Healing Hearts, to attend Camp Healing Hearts:

I agree to indemnify and hold harmless Camp Healing Hearts for any and all claims, demands, actions and judgments whatsoever of every name and nature, both in law and equity, which my child ever had or now has or may have against Camp healing Hearts for all personal injuries, either physical or emotional, known or unknown, and injury to property, sustained by my child's person or property during his or her attendance at Camp Healing Heart, including by not limited to, injury caused by or arising from Camp Healing Heart's own negligence.
I, the undersigned, have read this release and understand all of its items.

Your Electronic Signature:

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