Virtual Camp SHIELD 2021 Family Application

Camp SHIELD 2022

Thank you for your interest in Camp SHIELD! We look forward to you joining us. Please complete this application to register. Questions? Please contact us at 803-400-3299.
First *
First Name
Last *
Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone # *

Area Code Phone Number
Email *
name@address.com
Name *

First Name Last Name
Who are you are grieving? *
Name of the Deceased *

First Name Last Name
Date of Death *

Month Day Year
Age of the Deceased *
Relationship *
The Deceased was your _________
Cause of Death *

0/100
Are there any additional loved ones that you are grieving? *

Yes No
Name of the Deceased *

First Name Last Name
Date of Death *

Month Day Year
Age of the Deceased *
Relationship *
The Deceased was your _______
Cause of Death *

Please give the cause of death. 0/100
Are there any additional loved ones that you are grieving? *

Yes No
Name of the Deceased *

First Name Last Name
Date of Death *

Month Day Year
Age of the Deceased *
Relationship *
The Deceased was your _______
Cause of Death *

Please give the cause of death. 0/100
Have any of your family members received professional support? *
Have there been any other changes/stresses in your family's life? *
IE: Divorce, illness, relocation, etc.
Is there anything else you would like us to know about how your family is coping with the loss?

0/200
How many other family members will be attending Camp SHIELD? *
Up to 10 family members (parents, grandparents, siblings, children) can attend Camp SHIELD.
Please list all other family members attending Camp SHIELD. *
Do you have any other questions?
I understand that the cost to attend Camp SHIELD is $50 (up to 10 family members). *

Yes No
How did you hear about Camp SHIELD? *

Family Member Friend School Counselor Place of Worship Internet Search Media Facebook Instagram Twitter
Consent to Use of Photographic and Video Images: Jacoby's Shield may be photographing, videotaping, audiotaping or webcasting Jacoby's Shield meetings, activities, and Jacoby's Shield-sponsored events. Registration, attendance at, and/or participation at any of these events constitute an agreement by the registrant or attendee to these activities and to the use and distribution of the registrant’s or attendee’s image, likeness, or voice in photographs, videotapes, electronic reproductions, and audiotapes.
NOTE: Please be aware that registration fee is NON REFUNDABLE

Family Registration *

USD Registration is $50 for up to 10 family members.

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Camp SHIELD 2022

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