Spring 2023 Camp Jamie Teen Retreat Application

Camp Jamie Teen Retreat

Dear Parent/Guardian,

Thank you for your interest in Camp Jamie, Teen Grief Retreat, Spring 2023. Enclosed you will find an application packet for camp, which will be held on Saturday, March 25th, 2023.

Please complete and return the entire packet by March 10th, 2023, to 1 Frederick Health Way, Frederick MD 21701, or scan and email to griefsupport@frederick.health to be considered as a camper. We will be conducting phone interviews to help with the referral process.

Camp Jamie Teen Grief Retreat will be held at ThorpeWood Retreat Center at 12805 Mink Farm Rd, Thurmont, MD 21788. We will be asking that all campers arrive by 9:30AM at the main lodge at ThorpeWood. Campers will need to be picked up/leave by 7:30PM.

This one-day camp is designed to gently teach coping skills and help build self-esteem and trust. It also offers a safe, comfortable environment for teens to express their grief. Through interactions with other teens, adults, nature, and animals, campers experience the universality of loss and learn that they are not alone in their grief.

Licensed and trained counselors, as well as trained staff and volunteers, are part of the day camp experience, leading both large and small groups on issues such as sharing feelings, building trust, and memorializing loved ones through creative expression.

All of the participants will also experience the Equine Assisted Learning Program designed to build self-confidence, teamwork, and trust. Many other recreational activities are built into the day, making it a real camp experience. Campers will also enjoy hiking, arts, and crafts specifically designed to help them in their grieving process, and a remembrance ceremony around the campfire!

A day camp is just a small time frame, but we know we can truly make a difference in the life of a teenager, even in this short time period. The intention is to lay the foundation of communication, knowledge, and coping skills, upon which families can continue to build.

Please feel free to contact us if you have questions.

Sincerely,

The Hospice Bereavement Team

Bereavement History
1. Name of person(s) who died
2. Relationship to camper
3. Date of death

MonthDayYear
Date
4. Age of deceased at time of death
5. How did this person(s) die?
6. Was your camper present at the time of death?
Explain circumstances:
7. For campers bereaved by suicide, overdose, or homicide, are they aware of the circumstances of the death? How was this information shared with them?
8. Did they attend the funeral/memorial service?
If no, why not?
9. Please explain how they indicate that they are still grieving:
10. Have they received any professional support (i.e. psychologist, psychiatrist, school counselor, support group)? How long was the professional support provided?
11. Have they experienced any other deaths? Please explain:
12. Have there been any other changes/stresses in their life (i.e. divorce, illness, relocation, etc.) Please explain:

Explain:
** We ask that all children attending camp take their required medication prior to drop off at camp. If there are any issues regarding medication please explain above.

The information included in this application is correct so far as I know and the person described herein has my permission to attend Camp Jamie and participate in all camp activities.
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date

Camper Release of Liability

I understand and agree that Frederick Health Hospice, Frederick Health and it's Board of Directors, Officers, Employees, and Volunteers are released from any legal responsibility and/or liability for negligence arising out of any accidents or illnesses which occur while the child listed below attends Camp Jamie.
Name of child
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Camper Publicity Permission

Upon occasion, videotaping and/or photography may occur during camp activities. This material may be used for future publicity by Frederick Health Hospice, Frederick Health and its Board of Directors. In addition, with Hospice staff permission and supervision, the news media may wish to photograph, videotape, and/or interview some of the children attending camp. Please sign below if you have no objections to photographs, videotapes and/or interviews of your child.
Name of child
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date

ThorpeWood, LLC.
Property Use
Waiver & Release

I, the undersigned, as part of my, or my minor child's or children's, participation in any programs or classes offered by ThorpeWood. LLC. (hereinafter "ThorpeWood"), and use of the property and facilities owned by the Merle Thorpe, Jr. Charitable Trust and operated by ThorpeWood, LLC including but not limited to any ThorpeWood overnight programs or classes, do hereby acknowledge my understanding and agreement to the following:

I do hereby understand, acknowledge, consent and lagree, as part of the CAMP JAMIE TEEN CAMP program to be held at the ThorpeWood property located in Thurmont, Maryland on March 25, 2023 (hereinafter the "Program"), which Program I or my minor child or children, as indicated below, has/have applied to attend and participate, that the Program includes activities which may include hiking, fishing, experiences on the ground (ie. not in the saddle or riding) with horses at the ThorpeWood property and facilities, along with other children enrolled in the Progam. By signing below I hereby acknowledge, represent, and warrant that I am the parent or legal guardian of the minor child/children noted below, and I do hereby authorize my minor child/children to attend and participate in the Program.

I do hereby further waive, release, discharge, and agree to indemnify and hold harmless ThorpeWood, LLC and the Merle Thorpe. Jr. Charitable Trust and it's officers, directors, employees, contractors, volunteers, agents, and representatives, from and against any and all liability arising out of or incident to me or my minor child's or children's attendance and participation in the Program.
IN WITNESS WHEREOF, I have executed this Waiver and Release as of the date noted below.
WITNESS

Clear
Print witness name
WITNESS

Clear
Print witness name
PARTICIPANT

Clear
Print Participant name & date
PARENT/LEGAL GUARDIAN

Clear
Print name Parent/Legal Guardian & date
Print name(s) of minor child(ren)

ThorpeWood, LLC.
Horse Program
Waiver & Release

I am aware that being in the presence of horses poses potentially serious risks of injury or death to it's participants and that my horse or I may be injured or die as a result of my negligence, the negligence of others, or through no fault of mine or anyone else, because of the nature of the activity in which I am going to be engaged. I also understand that horses, even the most well-trained and sure-footed, can become unpredictable and difficult to control, and no one can foresee an equine's reaction to bee stings, excitement, weather conditions, sound, movements, objects, persons, animals, and the group dynamics of such situations.

By signing this release and waiver, I understand that I am giving up (waiving and releasing) any right I may have to sue or to make any subsequent claim against ThorpeWood, LLC., the owner of the horses, any ride leaders, helpers, their families or any private property owners.
Signature of horse program participant

Clear
Printed name
Signature of parent (if rider is under the age of 18)

Clear
Printed name of parent
Emergency contact information
Date

MonthDayYear
Date

Policy of Confidentiality

Bereaved persons that are served by Frederick Health Hospice understand that the discussion of their bereavement care remains within the Hospice team, with the following exceptions:

1) Court-ordered subpeonas
2) Information assessed in which there is clear and imminent danger to the
bereaved or to other people*
3) Known or suspected child abuse or neglect*
4) Known or suspected abuse, neglect, or exploitation of a vulnerable adult*

*These exceptions require immediate reporting to a proper care provider or ageny that can ensure the safety and appropriate interventions for all concerned.
I, blanks , understand the policy statement of Frederick Health Hospice's Bereavement Program regarding confidentiality and mandated reporting. fields and text.
Signature (Self/Parent/Guardian)

Clear
Date

MonthDayYear
Date
Should be Empty:

	Yes	No
1. Sleep disorders (i.e. sleep walking, bed wetting)
2. Eating disorders
3. Suicidal ideation/talking about wanting to die
4. Suicide attempts
5. Medication taken on a regular basis
6. Poor school attendance
7. Poor grades
8. Prior history of trauma
9. Lack of social skills
10. Difficulty getting along with peers
11. Difficulty getting along with adults
12. Difficulty getting along with family
13. Behavior problems
14. Physical limitations
15. Allergies
16. Asthma
17. Dietary restrictions
18. Convulsions/seizures
19. Diabetes
20. Ear infections
21. Hearing impairment
22. Vision impairment (including glasses or contacts)
23. Motion sickness
24. Nosebleeds
25. Mental health diagnosis
26. History of substance use (drugs or alcohol)
27. Autism Spectrum Disorder
28. Other

Camp Jamie Teen Retreat

Camp Jamie Teen Application

Behavior/Physical/Medical