Dear Parent/Guardian,

 

Thank you for your interest in sending your child to jhcamp.  We promise to make this a memorable experience for your child.  Enclosed is an information packet that includes all the necessary information to enroll your child in our weekend camp.

 

After you have completed and returned the entire packet, a grief counselor will contact you to talk firsthand about your child.  The counselor can give you an overview of what you can expect from the camp.  If we mutually determine that jhcamp can meet the needs of your child and there is space available, you will get a confirmation letter of your child’s acceptance.  We will be maintaining a waiting list for your next camp sessions as well.  If jhcamp is unable to meet your child’s needs, we will call to discuss that with you.

 

Parents/guardians are expected to provide their own transportation for dropping off and picking up their children at camp.  Camp registration is between 4:30-5:00 on Friday.  All parents/guardians enrolling their children are invited to attend a closing memorial service on Sunday afternoon.  Parents/guardians will have the opportunity to speak with camp staff and volunteers immediately after the closing session and discuss how the weekend was for your child.

 

Camp is limited to approximately 40 campers per session so please return your completed application promptly.  Mail application to:  jhcamp, 930 Via Mil Cumbres #1, Solana Beach, CA 92075. 

 

There is no charge for the camp thanks to grants and donations from the community.

 

We look forward to making this a rewarding, fun, and healing time for your child.  Please address any questions you may have to (619) 851-2672 or e-mail jhcamp@gmail.com.

 

Sincerely,

 

 

Neil R. Hiltz

Founder

CAMPER INFORMATION

 

Child’s Name and nickname:                                                                                             

 

School grade as of Fall of this year:                                                                                  

 

Age:                                                                                                                                       

 

Birth Date:                                                                                                                             

 

Sex:                                                                                                                                       

  

Race:                                                                                                                                     

 

School Attended:                                                                                                                 

 

PARENT/LEGAL GUARDIAN INFORMATION

 

Name of Parent or Legal Guardian:                                                                                   

 

Relationship:                                                                                                                         

 

Address:                                                                                                                               

 

Home Phone:                                                                                                                       

 

Work Phone:                                                                                                                         

 

Cell Phone:                                                                                                                           

 

e-mail:

 

EMERGENCY CONTACT INFORMATION

 

Contact Name:                                                                                                                     

 

Relationship:                                                                                                                         

 

Address:                                                                                                                               

 

Home Phone:                                                                                                                       

 

Work Phone:                                                                                                                         

 

Cell Phone:                                                                                                                           

 

HEALTH CARE INFORMATION

 

Physician Name:                                                                                                                  

 

Physician Phone:                                                                                                                 

 

Dentist Name:                                                                                                                      

 

Dentist Phone:                                                                                                                      

 

Hospital of Choice:                                                                                                              

 

Child’s Health Care Provider:                                                                                             

 

Effective Date:                                                                                                                      

 

Plan Number:                                                                                                            

 

Group Number:                                                                                                                     

 

Food Allergies:                                                                                                                     

 

Drug Allergies:                                                                                                                     

 

Other Significant Allergies:                                                                                                 

 

                                                                                                                                               

 

Please list any dietary restrictions (physician recommended, religious, etc.): 

 

                                                                                                                                               

 

                                                                                                                                               

 

GENERAL INFORMATION

 

Child’s Religious Affiliation (if any):                                                                                   

 

Has your child ever spent the night away from home (yes/no)?                          

 

Does your child have any sleep problems (sleepwalking, bedwetting, nightmares)?                                                                                                                          

 

Please list any sports/interests/hobbies that your child has:                                           

 

                                                                                                                                               

 

                                                                                                                                               

 

Please list any additional information (problems with eating, getting along with friends/peers/family, school attendance, physical limitations, etc.):                               

 

                                                                                                                                               

 

                                                                                                                                               

 

Child’s T-shirt Size (Child S/M/L, Adult S/M/L/XL):                                                          

 

How did you hear about jhcamp?:                                                                                      

Would you like to speak to a veteran camp parent (yes/no)?                                         

 

Please attach a photo of your child:

 

BEREAVEMENT HISTORY

 

Please include as many details as possible when answering these questions.  Attach extra pages if necessary.

 

Who was the person who died (name)?                                                                            

 

What was the relation to the camper?                                                                               

 

What was the cause of death?                                                                                           

 

When did the death occur (date)?                                                                                      

 

Age of camper when death occurred?                                                                              

 

Where did the person die (home/hospital/other)?  Please explain:                               

 

                                                                                                                                               

 

                                                                                                                                               

 

Was the camper present at the time of death (Yes/No)?  Please explain the circumstances:                                                                                                            

 

                                                                                                                                               

 

                                                                                                                                               

 

Did the camper attend the funeral/memorial service (Yes/No)?  If yes, what was the camper’s reaction to the service?                                                                                

 

                                                                                                                                               

 

                                                                                                                                               

 

                                                                                                                                               

 

Has your child received any professional support?  If yes, is support currently being provided?  If no, how long was the period of support provided?                     

 

                                                                                                                                               

 

                                                                                                                                               

 

                                                                                                                                               

 

Please explain how your child indicates that they are still grieving:                               

 

                                                                                                                                               

 

                                                                                                                                               

 

Have there been multiple deaths of loved ones experienced by the child (yes/no)?                                                                                                                            

 

                                                                                                                                               

 

Have there been any other changes/stresses in your child’s life (divorce, marriage, relocation, illness)?                                                                                        

 

                                                                                                                                               

 

 

CAMPER HEALTH HISTORY

 

Height:

 

Weight:

 

Health History (check those that apply):

 

     Attention Deficit Disorder (ADD)

     ADHD

     Emotional Problems (please explain):                                                             

     Acquired Immune Deficiency Syndrome (AIDS)

     Asthma

     Allergies

     Convulsions/Seizures

     Constipation/Diarrhea

     Ear Infections

     Motion Sickness

     Diabetes

     Fears (please explain):                                                                                      

     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 Contacts

     Other (please explain):                                                                                       

 

Please explain any information we need to know to care for the safety of your child:                                                                                                                                      

 

                                                                                                                                               

 

                                                                                                                                               

 

May we dispense Tylenol in the dosage appropriate for your child’s height and weight, if needed (yes / no)?                                                                                               

 

Last tetanus shot:                                                                                                                 

 

Are there any activities your child may not participate in while at jhcamp (yes/no)?  If yes, please explain:                                                                                     

 

                                                                                                                                               

 

                                                                                                                                               

 

 

To the best of my knowledge, the above information is correct and accurate.

 

                                                                                               

Signature of Parent/Guardian

 

 

I give permission to jhcamp to administer first aid to my child and authorize emergency transport to the nearest health facility.

 

                                                                                               

Signature of Parent/Guardian