2023 Camp Jamie Application Weekend

Dear Parent/Guardian,

Thank you for your interest in Camp Jamie 2023. Enclosed you will find an application packet for camp, which will be held on Friday, May 19th through Sunday, May 21st. This application packet gives you the opportunity to share information with us that we need to make this camp experience the most rewarding for everyone involved. Please complete and return the entire packet no later than Friday, May 5th, 2023 to 1 Frederick Health Way, Frederick MD 21701, or scan and email to griefsupport@frederick.health to be considered as a camper.

Please attach a photo of your camper to the application.

We have many children apply for camp each year and are only able to accommodate 25-30. We accept campers based on specific criteria (see enclosed form). While we don’t like to turn away children, at times it is necessary to do so. If your camper meets the criteria but is not invited to attend Camp Jamie this year, please apply again next year, or to our day camp in the fall. We would love to have your camper join us for a camp in the future.

Parents/guardians are strongly encouraged to attend an informational meeting about what your camper may expect from the camp experience. You may find the meeting to be helpful for you and we will be able to answer any questions you may have. The meeting will be held via Zoom on Wednesday, May 10th, 2023, from 6:00-7:30 PM.

**Please note that this meeting is for the parents and guardians only-- not children**

Camp Jamie will be held at Skycroft Conference Center, Middletown MD. We will be taking buses to and from the camp. We will be asking for the children to arrive at the Hospice Office on Friday, May 19th at approximately 4:15 PM, and be picked up at the Hospice Office on Sunday, May 21st at approximately 12:00 PM. Further information will be sent to you upon your camper’s acceptance.

If you have any questions about the application or about Camp Jamie, please call (240) 566-3030, Monday-Friday, 8:00 A.M. - 4:30 P.M., or email griefsupport@frederick.health. Remember that you will also be given the opportunity to ask questions when you come for the parent/guardian meeting. It is understandable that you may be somewhat anxious about the weekend. It is our hope to relieve any anxieties that you may have. We look forward to meeting you!

Sincerely,

The Frederick Health Hospice Bereavement Team

Love, laughter and leisure are the basic needs of all children, especially those who have experienced the death of a loved one. Frederick Health Hospice, in response to these special needs, established Camp Jamie in 1991.

Camp Jamie is a weekend experience, pairing children who are grieving with adults who can offer support and guidance. The adult volunteer acts as a “big buddy”, providing individual attention to the child for the entire camp weekend. All adult volunteers at Camp Jamie are specially screened and trained. They must meet the required criteria and have extensive background checks completed.

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

Hospice bereavement counselors lead both large and small group discussions and activities. Interventions focus on exploring and processing grief emotions, learning new ways to cope, and joining in the shared grief experience. Children participate in team building exercises, hiking, arts and crafts, drumming, and even toasting marshmallows around the campfire. Many of the activities offered allow for informal discussions between Big Buddies and Little Buddies, and among the children themselves.

A weekend is just a small time frame, but we know we can truly make a difference in the life of a child in this short time period. The intention is to lay the foundation upon which the families can continue to build. Meetings are held with the parents and guardians both before and after the camp to teach them about their child’s grief journey and how they, as caregivers, can be most supportive.

Approximately 25-30 children and 45 adults are invited to attend each camp. Children and adults alike develop valuable skills, form wonderful relationships, learn commemorative ways to honor the memory of their loved one and come away from the camp having their hearts deeply touched.

Criteria for Children Attending Camp Jamie…
- Must be in grades 1-8.
- Must have experienced a significant death.
- Frederick County Children are our first priority
- Must complete and return the application prior to the deadline date (see letter).
  - **Please note: Camp Jamie requests one completed application per child, regardless of shared household.
- Child must not have a history of or demonstrate any physically or verbally abusive behavior that could endanger others.
- Children may attend Camp Jamie overnight camp and day camp one time each only, unless there has been another significant death since the last camp experience.
- If more than one child per family is eligible to attend, siblings are encouraged to attend the same session.
Parents/guardians are encouraged to attend the informational meeting held prior to camp to have questions answered and receive assistance completing necessary paperwork, if needed.

After carefully considering the child's death history (emotional relationship with the deceased, nature of the death, support systems in place, etc.), the final decision of applicants accepted is at the discretion of the Camp Jamie directors.

PERSON TO CONTACT IN THE EVENT OF AN EMERGENCY
NAME
RELATIONSHIP TO CHILD
DAYTIME PHONE#
Please enter a valid phone number.
EVENING PHONE#
Please enter a valid phone number.
Has your camper ever spent the night away from home?

YesNo
Has your camper attended Camp Jamie in the past?

YesNo
If so, when?
Has your camper attended any bereavement camp in the past? If so, when and where?
Bereavement History
Name of person(s) who died
Relationship to your camper
What was your camper's relationship like with the person that died?
Date of death
Age of deceased at time of death
Age of child at time of death

How did this person(s) die?
a. How was the child told about the death? What was their reaction?
b. For overdose, homicide, and suicide, is your camper aware of the cause of death? How was it explained to them? (It is Camp Jamie policy that campers be aware of the cause of their loved one's death. We are happy to discuss this with you if you have questions about this policy, or would like guidance about how to share difficult information in an age-appropriate way.)
Did your camper witness the death? Please explain
Did your camper have an opportunity to say goodbye to the person before death? Please elaborate
Did your camper view the body or attend the funeral/memorial service? Please explain

Describe your camper's expression of grief (words, tears, anger, withdrawal, acting out, regression)
Has your camper received any professional support (i.e. psychologist, psychiatrist, school counselor, support group)? If so, with whom and for how long?
Has your camper experienced any other deaths? Please explain
Have there been any other changes/stressors in your camper's life before or after the death (i.e. divorce, illness, relocation, etc.)? Please explain

About Your Camper
1. List three to five words that describe your camper:
2. List some activities/hobbies your camper most enjoys:
3. What are your camper's strengths?
4. What motivates your camper? What discourages your camper?
5. What hopes and goals do you have for your camper's experience at camp?
6. Is there any other important information you would like to share about your camper?

25. Other
If yes was circled, please explain (include listed number)
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.

Clear
Date

MonthDayYear
Date

Please note:

If your camper takes prescription medications the attached form needs to be completed by your pediatrician/physician and signed by both you and the physician.

The form needs to be brought back to the Hospice office on Friday before departing to camp. It is to be handed into our Camp Jamie nurse, Molly.

We will not be able to take your camper to camp without the completed form.

Thank you.

Camp Jamie Staff

Camp Jamie Physician's Medication Order Form
Date

MonthDayYear
Date
To be filled out by physician ordering medication and returned to parent for delivery to Camp Jamie personnel.
Name

First NameLast Name
The following medications must be given during camp (List medication, dosage and time(s) to be given):
Administration (Specify water, milk, food, etc.)

For medications listed above, list all the side effects which should be observed by camp personnel.
List any reasons for not giving medication at the prescribed time (vomiting, fever, drowsiness, convulsions, etc.)
Physician's Signature

Clear
Date

MonthDayYear
Date

I authorize and request Camp Jamie personnel to administer the medication(s) prescribed by our physician, and in so doing relieve the camp, it’s agents, employees, or representatives of any responsibility for ill effects which may result from the administration of said prescribed medication.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Authorization of Over-the-Counter (OTC) Medication
In the event your camper complains of a headache or fever you would like us to administer Tylenol/Motrin for children
In the event your camper complains of stomach ache/nausea, you would like us to administer Pepto-Bismol
Please sign below on line and initial beside each of the above statements should you wish to have these administer to your camper.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date

Release of Liability
I understand and agree that I hereby release Frederick Health Hospice, Frederick Health and its Board of Directors, Officers, Employees, and its Volunteers, including but not limited to, Alison Bomba, Psy.D., and all licensed mental health professionals, from any and all claims, liabilities, and damages, consequential and punitive, for any reason pertaining to my child, and/or arising while my child is attending Camp Jamie.
Name of Child

First NameLast Name
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, including Frederick Health Hospice, and Camp Jamie community partners. 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

First NameLast Name
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Release of Address
I, Type a label, give Frederick Health Hospice permission to use.
(Parent/Guardian's name)
Type a label's name and address to share with others who attend 2023 Camp
(Camper's name)
Jamie for the purpose of encouraging communication between children, their "Big Buddies", and other campers.
Parent/Guardian Signature

Clear

Policy of Confidentiality
Bereaved persons that are served by Frederick Health Hospice understand that the discussion of their bereavement care remains confidential within the Hospice team, with two exceptions. The exceptions of confidentiality include information assessed in which there is clear and imminent danger to the bereaved or to other people, as well as known or suspected child abuse or neglect. The stated exceptions require immediate reporting to appropriate care providers 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.
Self/Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

	Yes	No
1. Sleep disorders (i.e. sleep walking, bed wetting, etc.)
2. Eating disorders
3. Poor school attendance
4. Poor grades
5. Lack of social skills
6. Difficulty getting along with peers
7. Difficulty getting along with adults
8. Difficulty getting along with family
9. Behavior problems
10. Mental health diagnosis
11. Diagnosis of Autism Spectrum Disorder
12. Individualized Education Plan (IEP) or 504 Plan
13. Physical limitations
14. Allergies
15. Asthma
16. Dietary restrictions
17. Convulsions/seizures
18. Diabetes
19. Frequent ear infections
20. Hearing impairment
21. Motion sickness
22. Nosebleeds
23. Wears glasses/contacts
24. Medications taken on a regular basis

Criteria for Children Attending Camp Jamie…

Bereavement History

About Your Camper

Social/Behavioral/Medical Assessment

Camp Jamie Physician's Medication Order Form

Authorization of Over-the-Counter (OTC) Medication

Release of Liability

Camper Publicity Permission

Release of Address

Policy of Confidentiality