Camp Erin Los Angeles 2023

Camper Application

Please note: All camp participants must be fully vaccinated against COVID-19. Campers who are unvaccinated at the time of application must be fully vaccinated at least 3 weeks prior to the start date of the camp date selected. If you're unvaccinated and don't plan to vaccinate before camp, contact jackie@ourhouse-grief.org for other grief camp referrals. 

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

We are currently accepting applications for both our June and September sessions. 

Please note: this application must be completed by the camper's parent/ legal guardian & a seperate application must be submitted for each camper

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

Household & Prospective Camper Health Information

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.

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. 

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. 

The questions in this section are used only for demographic statistics. 

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