Camp Hope Registration Form
Fill out the form carefully for registration
All about the student
Student Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Student's email (where applicable)
example@example.com
Student's Phone
-
Area Code
Phone Number
Name of School (currently enrolled)
*
Name of School (previously enrolled) - prior to Hurricane Dorian
Island of origin
*
Does your child suffer from any allergies, illness, disability, or other medical conditions?
*
Yes
No
If yes, please tell us about his/her condition or allergies.
Clear Fields
Clear Fields
Back
Next
Parent (1) Name
*
Prefix
First Name
Last Name
Parent (2) or Guardian Name
Prefix
First Name
Last Name
Address
Street Address
Town/Subdivision/Settlement
Island
Postal / Zip Code
Parent E-mail
*
Cell Number
*
-
Area Code
Phone Number
(another) Phone Number
-
Area Code
Phone Number
Work Number
-
Area Code
Phone Number
Emergency Contact
First Name
Last Name
Emergency Contact
-
Area Code
Phone Number
Please indicate if your child require transportation
*
Yes
No
Not sure
If yes, please provide specific directions to get to the house.
Back
Next
Impact of the storm
Does your child act or feel as if the Hurricane experience is happening again? Hearing something or seeing a picture about it and feeling as if they are there?
*
Yes
No
Uncertain
If yes, please provide details.
Does your child try to avoid activities people or places that remind them of the Hurricane?
*
Yes
No
Uncertain
If yes, please provide details.
Any behavioral or mood changes since the Hurricane experience?
*
Yes
No
Uncertain
If yes, please provide details.
What changes have the child undergone since the Hurricane? e.g. moved to another island, living with another family member, etc
*
Yes
No
If yes, please provide details.
Submit Application
Should be Empty: