Parent/Legal Guardian:
Relationship:
Address:
City:
State:
ZIP:
Home Phone:
Work: Phone:
Email Address:
Emergency
Contact:
Relationship:
Address:
City:
State:
ZIP:
Home Phone:
Work: Phone:
Name of Child’s
Physician:
Phone:
Name of Child’s
Dentist:
Phone:
Hospital of
Choice:
Child’s
Health Care Carrier:
Effective Date:
Plan Number:
Group Number:
Food Allergies:
Drug Allergies:
Other Significant
Allergies:
Please list
any dietary restrictions (physician recommended/religious, etc.):
Please list your child’s religious affiliation (if any):
Has your child
ever spent the night away from home?
Does your
child have any sleep problems (i.e. sleepwalking, bedwetting, nightmares)?:
Please list
any additional information (problems with eating, getting along with
friend/peers or family members, school attendance, physical limitations,
etc.):
Child’s
T-Shirt Size:
Adult:
How did you find out about Comfort Zone Camp®? (Please be specific. Thanks.)
Would you
like to speak to a veteran camp parent?
Please list
any sports/interests/hobbies that your child has:
Please email a photo of your child to us at info@comfortzonecamp.org
Comfort Zone Camp®
Bereavement History
Please include as
many details as possible when answering the following questions. Attach
extra pages if necessary.
1. Who was
the person who died (name):
2. How was
the person related to the child?
3. What was
the cause of death?
4. When did
the death occur (date)?
5. Age of
your child when the death occurred:
6. Where did
this person die?
Other
Please Explain:
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7. Was the
child present at the time of death?
Explain circumstances:
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8. Did the child attend the funeral/memorial service?
If yes, what was
your child’s reaction to / or comments about the service?
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9. Has your
child received any professional support (i.e. school counselor, peer
support group, psychologist, psychiatrist, pastoral counselor)?
(if no, skip to
#10)
If yes, is
support currently being provided?
If counseling
is no longer in progress, how long was the period of support provided?
10. Please explain how your child indicates that he/she is still grieving.
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11. Have there been
multiple deaths of loved ones experienced by this child?
If yes, please describe
the nature of death and the child’s relationship to the other
person who died.
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12.
Have there been any other changes/stresses in your child’s life
(i.e. divorce, remarriage, relocation, illness)?
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Comfort Zone Camp®
Health History Form
Camper’s
Name(Last) (First): _____________________________________________
Home Address: _________________________________________________________
Date of Birth:___________________
Age:__________ Sex:_______________
Child’s Height:__________________
Child’s Weight:_________________
Parent/Guardian’s
Phone (Day):____________________ Evening:__________________
Health History (check
those that apply):
_____ Attention Deficit Disorder (ADD) _____ ADHD_____ Emotional Problems
_____ Acquired Immune Deficiency Syndrome (AIDS) _____ Asthma
_____ Allergies (foods, animals, beestings) _____ Convulsions/Seizures
_____ Constipation/Diarrhea _____ Ear Infections _____ Motion Sickness
_____ Diabetes _____ Fears _____ Fainting _____ Heart Disease
_____ Hearing Impairment _____ Hepatitis _____ HIV _____ Kidney Disease
_____ Menstrual Cramps_____ Sickle Cell Anemia_____ Developmentally
Delayed
_____ Nightmares _____ Nosebleeds _____ Phobias _____ Special Dietary
Needs
_____ Wears Glasses_____ Wears Contact Lenses
_____ Other (please explain)_____________________________________________
Please explain
any information we need to know to care safely for your child:
_____________________________________________________________________
______________________________________________________________________
May we dispense
tylenol in the dosage appropriate for your child’s age and
weight, if needed? ___Yes ___No
Last Tetanus
Shot:__________
Medications:____________________________________________________________
Are there
any activities your child may not be able to participate in while at
camp?:___ Yes ___ No
If yes, please explain:_____________________________________
Physician’s Name:______________________________ Phone Number:___________
To the best
of my knowledge, the above information is correct and accurate.
______________________________________________________________________
Signature of Parent/Guardian Date
I give permission
to agents of Comfort Zone Camp® to administer first aid to my child
and authorize emergency transport to the nearest acute care facility.
______________________________________________________________________
Signature of Parent/Guardian Date
Comfort Zone Camp®
Physician’s Medication Order Form
This
form is to be filled out by the parent, signed by the physician ordering
medication and returned to Comfort Zone Camp®.
The following medications
must be given during the camp: Note: The first dose of any new medication
must be administered at home.
Name of Camper:__________________________________________________________
Medication Dosage
Time(s) to be given
1. ______________________________________________________________________
2. ______________________________________________________________________
3. ______________________________________________________________________
Administration (Specify
if medications are to be taken water, milk, food, etc.)____________
________________________________________________________________________
For medications
listed above, list all side effects that should be observed by camp
personnel.
1. ______________________________________________________________________
2. ______________________________________________________________________
3. ______________________________________________________________________
List any reasons
for not giving medication at the prescribed time (vomiting, fever, drowsiness,
convulsions):____________________________________________________
________________________________________________________________________
Physician’s
Signature:_________________________________ Date:_________________
Parental Authorization:
I / We authorize
and request Comfort Zone Camp® to administer the medication(s) prescribed
by our physician, and in so doing relieve the camp, its agents, employees
or representatives, of any responsibility for ill effects which may
result from the administering of said prescribed medication as per the
physician’s directions listed above.
______________________________________________________________________
Signature of Parent/Guardian Date
Comfort
Zone Camp
Indemnification Agreement
1. I, ________________________________, hereby give permission for my
child,
_________________________ to attend the Comfort Zone Camp® 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 interviewed during Comfort
Zone Camp under staff supervision. This material may be used for future
publicity of Comfort Zone Camp® including the news media.
_____ Yes _____
No
Release
3. In consideration
of the above-named child being granted permission by Comfort Zone Camp®,
Inc. to attend Comfort Zone Camp®,
I, for myself and
on behalf of my child, release and discharge Comfort Zone Camp®, Inc.,
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 Comfort Zone Camp® for all personal injuries,
either physical or emotional, known 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 fault.
By: ______________________________________________________________________
Indemnification Agreement
4. Also, in consideration
of the above-named child being granted permission by Comfort Zone Camp®
Inc., to attend Comfort Zone Camp® Inc.:
I agree to indemnify
and hold harmless Comfort Zone Camp®, Inc. for any and all claims,
demand,
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
Comfort
Zone Camp for all personal injuries, either physical or emotional,
known or unknown, and injury to property, real or personal, sustained
by my
child’s person or property during his or her attendance at Comfort
Zone Camp, including but not limited to, injury caused by or arising
from Comfort Zone Camp®’s own negligence.
I, the undersigned,
have read this release and understand all of its items.
DATE:___________________
___________________________________________
Parent/Guardian
DATE:___________________
___________________________________________
Parent/Guardian
Comfort Zone Camp®
Packing List
Camp Home Bedding
_____ _____ Sleeping Bag/Blanket & Sheets
_____ _____ Pillow
Clothing
_____ _____ Extra pair of shoes
_____ _____ Jacket, sweater, or sweatshirt
_____ _____ 2 Shirts – one long sleeve
_____ _____ 2 Pair shorts, 1 pair long pants
_____ _____ 3 Pairs socks
_____ _____ 3 Changes of underwear
_____ _____ 1 Pair of pajamas or sweat suit
_____ _____ Rain gear
_____ _____ 1 swim suit & towel (May-Aug camps)
Toiletries
_____ _____ Toothbrush and toothpaste
_____ _____ Deodorant—unscented
_____ _____ Soap/unscented in plastic bag
or plastic container
_____ _____ Bath towel
_____ _____ Washcloth in a zip-lock bag
_____ _____ Comb and brush
Other Items
_____ _____ Large flashlight w/extra bulb
and batteries
_____ _____ Sunscreen
_____ _____ Favorite stuffed animal
_____ _____ Hiking boots (optional)
_____ _____ Insect repellent (nonaerosol)
_____ _____ Water Bottle
_____ _____ Picture of Deceased Loved One
_____ _____ Shower shoes/Flip Flops
Note: If siblings are attending camp together, please send toiletries
for each child as they may be assigned to different areas. Comfort Zone
Camp does not allow items such as cell phones, radios, video games,
large amounts of money and other valuables are not to be brought to
camp. Comfort Zone Camp® will not be responsible for these items.
Comfort Zone Camp®
does not allow items such gum or candy to be brought to camp unless
given to a counselor to hand out to all campers. These items attract
insects such as bees and hornets. |