Name of Child Applicant
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Date of Birth
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Child's Age at time of camp - MUST BE 5 OR OLDER, NO EXCEPTIONS
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Child's Gender
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Ethnicity
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Grade in School - MUST BE K-12, No Exceptions
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Name of School Child Attends
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Child Special Talents, Skills or Unique Interests
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How did you hear about Camp Willow's Light?
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Is your child up-to-date on all vaccinations?
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Name of parent/guardian attending with child (at least ONE adult must attend camp with child)
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Does your child have any dietary restrictions, allergies (food or non-food) or hypersensitivities? (If yes, please explain; if no, please type N/A)
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Does the child have any medical, physical, or mental health issues or limitations? (If yes, please explain; if no please type N/A)
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Child's T-Shirt Size
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Does the child have any medications that will need to be taken at camp? If yes, please specify name dose, frequency; if none please type N/A
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Has your child/family attended Camp Willow's Light (previously named Camp Hands of Hope)?
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Relationship to child attending
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Name of additional parent/guardian attending with child
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Relationship to child
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Parent/Guardian Phone Number
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Emergency Contact Name
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Emergency Contact Phone Number
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Email Address
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Name of loved one who passed away
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Date of Death *MUST BE BETWAEEN 3 MONTHS - 3 YEARS FROM THE DATE OF CAMP
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If your child/family has attended camp before, please explain how the child has been doing since their last camp experience. (if no please type n/a)
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Has your child/family attended other bereavement camps? (if yes, please specify; if now, please type "n/a")
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If child was present at time of death, please explain circumstances (if not please type n/a)
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Relationship of deceased to child
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Please explain how your child has been grieving since the loss.
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Cause of death
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Have there been multiple losses of loved ones experienced by this child?
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Age of the deceased at time of death
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Has your child received any professional support to help with their grief?
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Have there been any other changes or stresses in your child’s life? (i.e., divorce, remarriage, relocation, illness, etc) if none please type n/a
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Other questions, comments, or concerns that you may have
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If yes, please tell us when the loss occurred and the child’s relationship to the additional person(s) that were lost. (if none please type n/a)
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Please list or explain any additional information you would like to share about your child and the way they handled the recent loss of their family member or friend.
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How many family members will be attending camp? Include the camper you just registered for in your count.
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I hereby certify that all the information above is accurate to the best of my knowledge.
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Please type your name below to certify this information.
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