Camp BraveHeart Registration
RequiredRequired Question(s)
We are honored that you are interested in sending your child to Camp BraveHeart. We at 3Hopeful Hearts, Pathways Hospice and Community Grief Center 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 do need a separate registration form for each camper, so we suggest if you have more than one child that you copy and paste into a word document and then it will make it easier for you if some of your answers are the same.
Please also feel free to email us at hope@3hopefulhearts.com if you need any questions answered. We will touch base with you as well. Thank you.
 
1.

This year our Camp is held over 2 days for certain ages. Saturday and Sunday July 22-23rd.
Please choose which of the following 3 options your child will participate in.
You may choose only one option. 

Ages 5-12- Saturday only from 9:00am - 4:00pm
Ages 12-18 Saturday 1:45pm - 8:30pm and Sunday 8-noon (day option only)
Ages 12-18 Saturday and Sunday (overnight option) 1:45pm (Sat) - noon (Sunday)
2.
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 3.

Your cell phone number.

 

50 characters left.
EMERGENCY CONTACT INFORMATION
 
Required 4.
Emergency Contact Name and Cell Number.
 

50 characters left.
CAMPER  INFORMATION
 
Required 5.
Your campers first and last name.  Please indicate your campers age with their birthdate after their name.
 

350 characters left.
Required 6.

Name to appear on your child's badge.

 

350 characters left.
Required 7.

Name of your child's school and grade this coming fall-2017. 

 

350 characters left.
FAMILY INFORMATION
 
Required 8.
Please list other family members  living with your camper including siblings.
 

1000 characters left.
Required 9.

What are your child's hobbies and interests?

 

1000 characters left.
HEALTH INFORMATION
 
Required 10.
Your child's physician and phone number.
 

350 characters left.
Required 11.

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

 

1000 characters left.
Required 12.

Dietary Restrictions

 

1000 characters left.
BEREAVEMENT HISTORY
 
Required 13.

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.

 

1000 characters left.
Required 14.

What was the cause of death?

Are there any circumstances we should be aware of?

 

1000 characters left.
Required 15.

Did your child attend the service or funeral?

yes
no
16.

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

 

1000 characters left.
Required 17.

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

yes
no
18.

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 19.

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 20.

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 21.

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 22.

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 2017 Camp BraveHeart!

3Hopeful Hearts- hope@3hopefulhearts.com
Pathways Hospice -tammy.brannen-smith@pathways-care.orgĀ 
Community Grief Center -eaglesnest33@comcast.netĀ