*Choice of Location
*Camper Name:
*Address:
*City:
*State:
*Zip:
*Date of Birth:
*Gender:
*Age:
*Parent/Guardian Name:
*Parent/Guardian attending camp?
Parent/Guardian tee shirt size
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
*Home Phone:
*Work Phone:
Email address:
*Camper tee shirt size:
Youth Small
Youth Medium
Youth Large
Youth X-Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
*How did you hear about Rainbow Trails Camp?
*Please identify the nature of your loss or the reason for your application:
*Has your child attended Rainbow Trails in the past?
*Will any relative of this camper also be going to camp?
*If yes, please list names:
Medical Information:
*Emergency Contact:
*Relationship:
*Emergency Phone Number:
*Does your child have any health problems?
*If yes, please identify:
*Does your child have any allergies?
*If yes, please list:
*Is camper on any medication?
*If yes, please list medication and dosage:
All medication must be given to the camp nurse at the Registration Table when registering camper. Medication must be in a prescription container with clearly marked Name/Address/Instructions.
Please supply enough for one day only. Do not send over-the-counter medications. PLEASE, DO NOT MIX MEDICATIONS IN ONE BOTTLE.
*Has your child been taking any medications regularly that have recently been stopped?
*Please explain:
*Does your child have any disabilities?
*If yes, please list:
Is there any reason your child may not be able to participate in recreational activities?
Descriptive Information
On a scale of 1 - 10 with "1" being "doing great" and "10" being "absolutely terrible," indicate how your child is doing on the various concerns listed.
*Depression
1
2
3
4
5
6
7
8
9
10
*Anxiety
1
2
3
4
5
6
7
8
9
10
*Fear
1
2
3
4
5
6
7
8
9
10
*Anger
1
2
3
4
5
6
7
8
9
10
*Acting Out
1
2
3
4
5
6
7
8
9
10
*Missing loved one
1
2
3
4
5
6
7
8
9
10
*Withdrawn
1
2
3
4
5
6
7
8
9
10
*Very Social
1
2
3
4
5
6
7
8
9
10
*Problems at school
1
2
3
4
5
6
7
8
9
10
*Clinging/dependent
1
2
3
4
5
6
7
8
9
10
*Makes friends easily
1
2
3
4
5
6
7
8
9
10
*Loss of self esteem
1
2
3
4
5
6
7
8
9
10
*Guilt
1
2
3
4
5
6
7
8
9
10
*Schoolwork
1
2
3
4
5
6
7
8
9
10
*Open/outgoing
1
2
3
4
5
6
7
8
9
10
*Problems at home
1
2
3
4
5
6
7
8
9
10
*Very quiet
1
2
3
4
5
6
7
8
9
10
*Hyperactive
1
2
3
4
5
6
7
8
9
10
*Problems sleeping
1
2
3
4
5
6
7
8
9
10
*Fearful
1
2
3
4
5
6
7
8
9
10
*Enjoying life
1
2
3
4
5
6
7
8
9
10
*How long has your child been dealing with this grief or loss?
*Are there any additional issues your child may be dealing with that the counselors should be made aware of? Please explain.
*Was the death or loss caused by someone?
*If yes, please explain:
*If this was a violent act or death, was the child a witness or present at the time?
*If yes, please explain the circumstances:
*Is your child being seen by a counselor at this time?
Please describe any problems or restrictions your child may have:
Hold Harmless and Release of Information Agreement
In consideration of Hope HealthCare Services, permitting the undersigned the privilege of attending Rainbow Trails Summer Camp Program.
We (I) hereby agree to indemnify and hold harmless Hope HealthCare Services and staff against, of and from any and all claims of any kind or nature,
I hereby give permission to share the information in this application with the staff of Rainbow Trails.
I also give permission for the Nursing staff of Rainbow Trails to administer prescription and non-prescription medications.
Should there be an emergency, I also give my permission to the doctors and hospitals to treat my child as may be necessary.
*I give permission for my child to be photographed.
I further agree to and give permission for Hope Hospice to use any and all photos and recordings of camp activities for promotional use including television, newspaper, website and other printed literature.
Camper Rules:
1. No smoking, drugs or alcohol.
2. No cell phones, radios, tape players, or other electronic equipment.
3. No roughhousing (all campers must keep their hands to themselves and are not allowed to kick, hit, or in any way hurt each other).
7. No camper may leave their assigned group at anytime without permission of their counselor.
8. Campers are encouraged not to bring money to camp, and if they do, it is at their own risk.
9. Campers must remain with assigned counselor at all times.
I HAVE READ THE CAMP RULES, UNDERSTAND THEM, AND AGREE TO FOLLOW THEM, and I FURTHER UNDERSTAND THAT IF I BREAK THESE RULES, I WILL BE ASKED TO LEAVE AND MY PARENTS/GUARDIAN WILL BE EXPECTED TO PICK ME UP.
I have read and consent to the “Hold Harmless and Release of Information” agreement.
By checking the box below, you agree, warrant and covenant that you have read and will honor all terms in this agreement:
*Camper:
*Parent/Guardian:
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