Camp BraveHeart Registration
RequiredRequired Question(s)
We are honored that you are interested in sending your child to Camp BraveHeart on July 22nd. We at 3Hopeful Hearts and Pathways Hospice would like to get to know your camper and we also understand that grief is individual. By sharing your loved one's story and your child's background we feel we can better help them make the best of their experience at Camp BraveHeart.
Please allow apx 20 minutes to complete this registration. We will follow up with a personal phone call once you have submitted this form online to answer any questions you may have. Please also feel free to call us at 970-430-6136 or email us at hope@3hopefulhearts.com if you need any questions answered before we contact you. Thank you.
 
Required 1.
This first section is information for the parent or guardian of the camper.

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
City:
Postal Code:

Required 2.

Your cell phone number.

 

50 characters left.
EMERGENCY CONTACT INFORMATION
 
Required 3.
Emergency Contact Name and Cell Number.
 

50 characters left.
CAMPER INFORMATION
 
Required 4.

Your camper's first and last name.

 

50 characters left.
Required 5.

Name to appear on your child's badge.

 

50 characters left.
Required 6.

Your child's age and birthdate.

 

50 characters left.
Required 7.

Gender

Male
Female
Required 8.

Name of your child's school and grade this coming fall-2016.

 

50 characters left.
FAMILY INFORMATION
 
Required 9.
Please list family members and ages of other siblings (or children) living with your camper.
 

1000 characters left.
Required 10.

What are your child's hobbies and interests?

 

350 characters left.
HEALTH INFORMATION
 
Required 11.
Your child's physician and phone number.
 

50 characters left.
Required 12.

Allergies- (Please include reactions and any other pertinent information).

 

1000 characters left.
Required 13.

Dietary Restrictions

 

350 characters left.
BEREAVEMENT HISTORY
 
Required 14.

Please share with us the person(s) who has died ( name, date of death and age at time of death) and the relationship to your child.

 

350 characters left.
Required 15.

What was the cause of death?

Are there any circumstances we should be aware of?

 

1000 characters left.
Required 16.

How old was your child at the time of this loss?

 

50 characters left.
Required 17.

Did your child attend the service or funeral?

yes
no
18.

If yes, please explain your child's reaction/comments/memories about the service.

 

1000 characters left.
Required 19.

Has your child received any professional support( i.e. school counselor, support group, psychologist or  pastoral support)?

yes
no
20.

If yes, please explain if this has been a positive experience for your child or not a positive experience and why.

 

1000 characters left.
Required 21.

Have there been any other deaths in the family or with friends or acquaintances where your child has been affected? (Please explain)

 

1000 characters left.
Required 22.

Have there been any other changes/stresses in your child's life( i.e. divorce, remarriage, new school, relocation, illness etc.)? If yes, please explain.

 

1000 characters left.
Required 23.

Please explain how your child indicates that he/she is grieving (sadness, anger, isolating, acting out, wanting more attentions , regressing etc).

 

1000 characters left.
Required 24.

Is there anything in closing that you think would be most helpful for us to know about your child at this time?

 

1000 characters left.
We look forward to meeting and spending the day with your child at our 2016 Camp BraveHeart!

3Hopeful Hearts and Pathways Hospice