Chaptershealth.org

Office Use Only
LifePath Hospice
2014 Camp Circle of Love Application
CAMPER INFORMATION (Please print and complete in entirety)
Name:

PARENT/ GUARDIAN INFORMATION
Name: (1)
Person to Contact in Case of Emergency and Phone #: (Do not leave blank)
OTHER HOUSEHOLD MEMBERS (siblings, grandparents, etc.)
Relationship to Child
Attending Camp
This Year?
Name of person who died (list primary loss if more than one) Circumstances of death (illness, sudden death, accident, involvement of child):
Behavior (please describe-- problems in school, with peers, friends, family, fighting, excessive
sadness, withdrawn from others, and any other behavior changes since the death):
Has your child ever spent the night away from home; away from immediate family? Yes No Has child attended Camp Circle of Love previously? Yes No If yes, what year?_________ How does your child feel about coming to camp? ______________________________________ Does your child have any sleep problems (sleepwalking, fear of the dark, bedwetting, nightmares)? Yes No If yes, please explain: Please list any interests/hobbies/talents your child has: Can your child swim? Yes No I understand that the acceptance of my child at camp is contingent upon space availability and an assessment by a Bereavement Specialist. CAMP DATES ARE APRIL 25 – April 27, 2014

After completion of camper application(s) call (813)357-5609 to schedule a camper interview. Deadline
for camp is April 18, 2014. There is a sliding scale fee for camp based on income ranging from $1 - $25.
Fee will be collected at the time of the camper interview.
Office Use Only
2014 CAMP CIRCLE OF LOVE MEDICAL RELEASE

EMERGENCY CONTACT INFORMATION
Primary Emergency Contact (Parent/Guardian)
Alternate Emergency Contact
(DO NOT LEAVE BLANK)
Any medical problems?: Has your child ever had a reaction or allergy to any medications? Yes No If yes, which medication(s)
Does your child have any food allergies? Yes No Any other allergies? Yes No
If yes, allergic to
What type of reaction does your child have?
MEDICATIONS Does your child take medication(s)? Yes No

Name of Medication
When Taken
Reason for Medication
(include prescription and
Medication
over-the-counter
medications)

PERMISSION TO ADMINISTER ABOVE MEDICATIONS, FIRST AID AND EMERGENCY CARE TO MY CHILD IS HEREBY GIVEN: Signature:
Note: All medications must be given to the Camp Nurse at camp check-in and reviewed
with the Nurse. If there have been any recent changes in medications taken by your child make sure
to tell the nurse. All medications must be in prescription containers and be clearly marked with the above
information
Over-the Counter Medication Release
As Parent/Guardian, I give the medical staff permission to administer the following over-the-counter medications listed or suitable generic substitute to the camper named above if they deem it necessary. Dosages will be administered according to directions on the bottle for camper’s age/weight unless a physician directs otherwise. I hereby certify that I or my child has not in the past shown any allergic or other adverse reaction to any of the medications which you are hereby authorized to administer. PERMISSION
(Please leave no
MEDICATION
squares blank.)
Calamine Lotion, Cortaid, Caldyphen or Caldryl Dristan Cold, Sudafed, or Pseudoephedrine with Tylenol PARENTAL CONSENT AND RELEASE OF LIABILITY
On behalf of myself, as parent or legal guardian, and my child(ren) listed below attending Camp Circle of Love, presented by LifePath Hospice, Inc. (“LPH”), a wholly-owned subsidiary of Chapters
Health System, Inc. (“Chapters”), I hereby agree as follows:
I hereby give permission for my child(ren) listed below to attend Camp Circle of Love I hereby acknowledge that sufficient information has been provided to me regarding the activities planned for Camp Circle of Love. I hereby acknowledge that certain risks of injury are inherent to participate in Camp Circle of Love activities. I understand that the safety and protection of the participants in Camp Circle of Love is paramount, and, therefore: Agree that my child(ren) listed below wil abide by all instructions, rules, or regulations provided by LPH staff and/or volunteers; and Agree that my child(ren) listed below may be required to inventory belongings in the presence of LPH staff if the health or safety of other participants or staff and/or volunteers
Acknowledging the foregoing, and in consideration for LPH granting my child(ren) access to
Camp Circle of Love, I understand and agree, on behalf of myself and my child(ren) listed
below, that LPH, Chapters and each of those entities’ officers, directors, employees,
volunteers and agents are hereby released and discharged from any and all claims, demands,
losses and causes of actions of every kind whatsoever, including without limitation any and
all causes of action based upon a theory of negligence and any and all liability for damages of
every kind, nature or description which may arise from or out of injuries and damages,
permanent or otherwise, which occur while my child(ren) listed below attend Camp Circle of
A parent or guardian of a child attending Camp Circle of Love must sign below and write the following “I have read, understand, and agree to this consent and release.”
__________________________________________________________________________ Parent’s or Guardian’s Name (printed)
Name(s) of child(ren) attending Camp Circle of Love:
MEDIA RELEASE
Upon occasion, videotaping and photography may occur during various Camp Circle of Love activities, and this material may be used by LifePath Hospice, Inc. (“LPH”) or Chapters Health System, Inc. (“Chapters”) in future
marketing and publicity. In addition, the news media may wish to photograph, videotape and/or interview participants for news coverage of the Camp Circle of Love. When LPH knows of such previously scheduled media activities, LPH will inform you in advance of any details pertaining to such scheduled occasions. If you agree to being photographed, videotaped and/or interviewed, and/or agree to your child(ren) or ward(s) identified below being photographed, videotaped and/or interviewed, please mark the appropriate box and sign
I hereby give permission for myself and, if applicable, my minor child(ren) or ward(s) listed below, to
appear in publicity or news coverage regarding Camp Circle of Love, as described above. I hereby
release and discharge LPH and Chapters, and each of those entities officers, directors, employees,
volunteers and agents, from any and all claims and demands arising out of or in connection with the
use of the videotapes or photographs, including without limitation any and all claims for libel or
invasion of privacy.
____ I give permission with the following EXCEPTIONS: _____________________________________________________________________________________ ____________________________________________________________________________________.
If signing on behalf of your child(ren) or ward(s) who are participating in Camp Circle of Love, please
identify each child and/or ward below (use additional sheets if necessary):
Child/Ward:_____________________________ Relationship:___________________________ Child/Ward:_____________________________ Relationship:___________________________ Child/Ward:_____________________________ Relationship:___________________________

Source: http://www.chaptershealth.org/docs/default-source/default-document-library/camp-circle-of-love-camper-application.pdf?sfvrsn=5