Camper Application 2023

Camp Erin Los Angeles 2023

Camper Application
Please note: We are no longer requiring proof of vaccination for our camp participants.

** A seperate application must be completed for each camper**

We are currently accepting applications for our September session.
This summer we are hosting both an overnight camp and a day camp. Please mark the session your child(ren) would like to the attend:
Has your child attended Camp Erin before?
If Yes, was it Camp Erin Los Angeles?
Has your child participated in an OUR HOUSE Group?

Other
Please note: this application must be completed by the camper's parent/ legal guardian & a seperate application must be submitted for each camper
Camper Legal Name (This is only for our record and will not be shared with anyone other than camp administrators)

First NameLast Name
Name the Camper prefers to be called (if different from above)
Camper's Gender
Examples include: girl, boy, nonbinary, etc.
Camper's Pronouns (What words would your camper like us to use when not referring to them by name? ie. she/her, he/him, they/them, etc.)
Date of Birth (mm/dd/yyyy)

MonthDayYear
Date
Camper T-Shirt Size (please mark one)
Camper has: (please mark all that apply)
Camper's Primary Language + All Fluent Languages
Grade
School
Age of Camper by June 2023:
Please describe the Camper's personality/character traits
Please list the Camper's interests and hobbies
Which best describes the Camper's reaction to the possibility of attending Camp Erin LA?

Other
*Note: we ask that all campers be told by their caregiver about Camp Erin LA prior to their interview

Household & Prospective Camper Health Information

Household Information:

Rows	Name	Age	Relationship to Camper
Household Member 1
Household Member 2
Household Member 3
Household Member 4

Prospective Camper Health Information: Please mark any of the following that apply to the camper:

Rows	Yes	No
Asthma
Convulstions/Seizures
Diabetes
Chronic Ear Infections
Hearing Impairment
Nosebleeds
Wears Glasses/Contacts
Recurring Headaches or Stomacheaches
Other (we will ask you to specify)

Has the Camper been fully vaccinated against COVID-19? (Excluding boosters)

Other
Does the Camper have any special needs, physical limitations, diagnosed mental illness, and/or developmental/learning disabilities (IEP, OT services)? If Yes, please explain.

Yes
Does the Camper have any history of operations or serious illnesses? If Yes, please explain.

Yes
Does the Camper have any dietary restrictions? (physician recommended, religious, etc) If Yes, please list below.

Yes
Does the Camper have any allergies? (to food, medicine, environment, seasonal, etc.) If Yes, please list below.

Yes (Please note how this presents)

Will the Camper be taking medications at camp? If yes, please list the medication and what they are treating.

Rows	Name of medication	Dosage & Schedule	What is it treating?
Medication 1
Medication 2
Medication 3
Medication 4

PARENT/LEGAL GUARDIAN INFORMATION

For Session 1, please include information for the camper's guardian below.

For Session 2, the day camp schedule includes an adult program that requires the participation of one parent/guardian per family. We will be providing adult programming in parallel to your camper's experience throughout the camp day. Adults will participate in a range of grief and fun activities, meet other camper guardians and witness the closing Luminary Ceremony of your campers. We require 1 guardian to attend camp. Below please provide information regarding the accompanying guardian.
Accompanying Guardian Full Name:

Guardian First NameGuardian Last Name
Relationship to Camper:
Guardian's relationship to the person who died:
Is the Guardian currently connected to psychosocial support/services? If Yes, please list what type of support/services and length of time received.

Yes
Guardian's preferred language + fluent languages
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from above)
Has caregiver participated in an OUR HOUSE grief support group themselves?

Emergency Contacts: Please list two local people other than the accompanying adult that we can contact in case of an emergency.

Rows	Name	Relationship to Camper	Phone Number
Emergency Contact 1
Emergency Contact 2

How did you learn about Camp Erin LA? (please mark all that apply)

Other
Would you like to receive communication about OUR HOUSE Grief Support Center programs and events?
Bereavement & Family History

Please tell us about the significant person(s) the Camper is grieving.
First & Last Name of the Person Who Died

First NameLast Name
What the Camper called their Person(s) Who Died
Relationship to Camper:

Other
Was the deceased a significant caregiver of the camper?
Date of Death (mm/dd/yyyy)

MonthDayYear
Date
Age of Person Who Died at Time of Death
Camper's Age at Time of Person's Death
Cause of Death
The Death was:
We understand that these questions may be difficult to answer. This information helps us to better support your Camper in their geif and provide the best possible care.
Was the Camper present at the time of death?
Did the Camper see their person who died, after the death?
Did the Camper attend the funeral / memorial service, if one was held?
Please mark if either statement applies to your Camper:
If you marked one of the above, please explain
Please note: It is in your Camper's best interest to know the true cause of death. Therefore, it is a requirement of Camp Erin LA that Campers know the true cause of death, if it is known to the family. Camp Clinical Staff are available to assist you in having this conversation with your Camper and to provide clinical rationale for this requirement.
Did the Camper live with the person who died

No (if no, please describe what kid of contact and how frequently the Camper was in contact with the person who died)
Please describe the type of relationship the camper had with their person who died.
Describe how the camper reacted to the death?
How would you describe the Camper's communication regarding the death?
How would you describe the Camper's family's communication regarding the death?
Please describe how the Camper indicates they are grieving.
Is this the Camper's first experience with death?

No, please explain the other deaths the Camper has experienced, including (1) Who died (2) Date of Death (3) Cause of Death
Is the Camper displaying any behaviors and/or moods that concern you?

If Yes, please explain
Camper's Reaction to the Death

Please mark any of the following that the Camper has exhibited since the death(s) of their significant person(s).
Physical Changes
Thoughts & Feelings
Behaviors
How has your Camper's social and emotional wellbeing / grief been impacted by the COVID 19 pandemic?
Has the Camper ever witnessed or experienced violence of any kind?

If Yes, please explain
Has the Camper ever been removed from their home due to abuse or neglect of any kind?

If Yes, is there currently an open case with the Department of Child and Family Services?
Has the Camper received any professional psychosocial support?

If Yes, what was the reason for the Camper receiving services?
If Yes, please mark all that apply:

Other
Is the Camper currently connected to psychosocial support/services?

If yes, please list what type of support/services and length of time received
Please explain any family customs, religious/faith practices or cultural aspects to the Camper's grieving that we should be aware of to better support them.
Anything else you would like us to know about your camper?
Please upload a photo of your camper:

Cancelof
Please upload proof of camper AND guardian COVID-19 vaccination record:

Cancelof
The questions in this section are used only for demographic statistics.
# of People in Household
# OVER Age 18
# UNDER Age 18
Family Income
Does the camper applicant qualify for, or receive, free or reduced lunch at school?
Camper Race/Ethnicity (please mark all that apply)

Other
Is the Camper's Parent/Guardian and/or the person who died affiliated with the military as active duty, reserve, or veteran?

If Yes, Please share which branch
Guardian's Name
Guardian's Signature
Date

MonthDayYear
Date
If you have any questions regarding Camp Erin LA, please contact Jackie Eppinger, Associate Clinical Coordinator of Camp, at (310)231 3186 or jackie@ourhouse-grief.org.

Consent to Release Information
(OUR HOUSE Grief Support Center Staff to Provider)

Signing this document authorizes OUR HOUSE Grief Support Center to communicate with your mental health (therapist or psychiatrist) or healthcare (medical doctor) provider regarding grief support groups and your interaction with OUR HOUSE staff. Should your safety and/or the safety of another be of concern, this consent is required to allow us to collaborate with your healthcare team to provide you the best care possible. Failure to provide all information requested will impede our ability to collaborate with those who know you best.
I consent for OUR HOUSE Grief Support Center to exchange information regarding my camper with my their therapist/healthcare provider. This consent allows OUR HOUSE Grief Support Center to release information regarding my child'sparticipation in group as well as interactions with agency personnel including, but not limited to my child's attendance to group sessions, behaviors and verbalizations regarding safety concerns and emotional states.

I consent for my child's therapist/healthcare provider, to exchange information with OUR HOUSE grief Support Center. This consent allows my child's Therapist/ Healthcare Provider to provide the following information: adherence to treatment including attending appointments, taking medications as prescribed, clinical risk assessments(including, but not limited to suicidality, homicidality and/or grave disability), participation in treatment planning, psychiatric hospitalizations and any other pertinent information that may impact group participation.

This consent expires one year from the date of authorization indicated by the signature at the bottom of this page
I consent for OUR HOUSE Grief Support Center to exchange information regarding my camper with my their therapist/healthcare provider and for my child's therapist/healthcare provider, to exchange information with OUR HOUSE Grief Support Center
Name of therapist/healthcare provider:
Address of therapist/healthcare provider:
Phone of therapist/healthcare provider
Guardian's Name

First NameLast Name
Camper's Name

First NameLast Name
Signature
Today's Date

MonthDayYear
Date
Should be Empty:

Bereavement & Family History

Camper's Reaction to the Death