Camp Erin Application
Solace House/Kansas City Hospice & Palliative Care
Which Camp are you applying for:
Camp Erin Family Day Camp- July 15, 2023
Camp Erin Family Weekend Camp- September 15-17th, 2023
Both Camps
1. Primary Family Contact (Name)
2. Email (Camp communication occurs primarily through email)
example@example.com
3. Address (City, State, Zip)
4. Relationship to Children Applying
5. Emergency Contact (Name, Phone Number)
Grief History
1. Name of Person Who Died
2. Date of Death
3. Age at Death
4. Cause of Death
Illness
Sudden/Accidental
Homicide
Suicide
Covid-19 related
Other
5. Was the deceased in the military?
No
Yes
If yes, what branch?
6. Was there a funeral/memorial service?
Yes
No
If yes, did the child/children attend the funeral/memorial service?
Yes
No
7. Please briefly describe your family's experience during your loved one's illness/death: length of illness, place of death, your children's knowledge/awareness of the situation, etc.
8. What concerns do you have about you or your children's grief?
9. Are there additional losses you would like tell us about?
Please complete the following participant information for ALL FAMILY MEMBERS ATTENDING CAMP:
Participant 1
Name (First and Last)
Age
DOB
Gender
Male
Female
Non-binary
Ethnicity (optional)
White
Black or African American
American Indian or Alaska Native
Asian
Hawaiian or Pacific Islander
Other
Name of School (Children Only)
Relationship to Deceased
T-Shirt Size
Child/Small
Child/Medium
Child/Large
Child/XL
Adult/Small
Adult/Medium
Adult/Large
Adult/XL
Adult/2X
Adult/3X
Participant 2
Name (First and Last)
Age
DOB
Gender
Male
Female
Non-binary
Ethnicity (optional)
White
Black or African American
American Indian or Alaska Native
Asian
Hawaiian or Pacific Islander
Other
Name of School (Children Only)
Relationship to Deceased
T-Shirt Size
Child/Small
Child/Medium
Child/Large
Child/XL
Adult/Small
Adult/Medium
Adult/Large
Adult/XL
Adult/2X
Adult/3X
Participant 3
Name (First and Last)
Age
DOB
Gender
Male
Female
Non-binary
Ethnicity (optional)
White
Black or African American
American Indian or Alaska Native
Asian
Hawaiian or Pacific Islander
Other
Name of School (Children Only)
Relationship to Deceased
T-Shirt Size
Child/Small
Child/Medium
Child/Large
Child/XL
Adult/Small
Adult/Medium
Adult/Large
Adult/XL
Adult/2X
Adult/3X
Participant 4
Name (First and Last)
Age
DOB
Gender
Male
Female
Non-binary
Ethnicity (optional)
White
Black or African American
American Indian or Alaska Native
Asian
Hawaiian or Pacific Islander
Other
Name of School (Children Only)
Relationship to Deceased
T-Shirt Size
Child/Small
Child/Medium
Child/Large
Child/XL
Adult/Small
Adult/Medium
Adult/Large
Adult/XL
Adult/2X
Adult/3X
Participant 5
Name (First and Last)
Age
DOB
Gender
Male
Female
Non-binary
Ethnicity (optional)
White
Black or African American
American Indian or Alaska Native
Asian
Hawaiian or Pacific Islander
Other
Name of School (Children Only)
Relationship to Deceased
T-Shirt Size
Child/Small
Child/Medium
Child/Large
Child/XL
Adult/Small
Adult/Medium
Adult/Large
Adult/XL
Adult/2X
Adult/3X
Participant 6
Name (First and Last)
Age
DOB
Gender
Male
Female
Non-binary
Ethnicity (optional)
White
Black or African American
American Indian or Alaska Native
Asian
Hawaiian or Pacific Islander
Other
Name of School (Children Only)
Relationship to Deceased
T-Shirt Size
Child/Small
Child/Medium
Child/Large
Child/XL
Adult/Small
Adult/Medium
Adult/Large
Adult/XL
Adult/2X
Adult/3X
Additional Family Information
1. It is common for grieving families to experience other challenges that make it difficult to cope with grief. Have you experienced any of the following? Financial Job Loss/ Other Deaths/ Moves/ Loss of Pet/ Job Change/ Change in School/ Divorce or Seperation/ Other Health Difficulties?
2. Have you or your children previously received grief support from Solace House or other social service organizations?
3. Does your family qualify for Free or Reduced School Lunch?
Yes
No
4. Are any members of your family (attending Camp Erin) healthcare professionals?
5. Does your family have a religious or spiritual affiliation? (optional)
6. Are there any family customs or cultural aspects to your family's grieving that we should be aware of?
7. What do you hope you and your children get out of your experience at camp?
8. Is there additional information we should be aware of to better serve your family?
9. How did you learn about Camp Erin?
Date of application
/
Month
/
Day
Year
Date
There is no cost for families for Camp Erin. Applications are processed first-come first-served and spaces are limited. Once we receive your application, we will be in touch to schedule an interview/orientation with your family. Thank you for your interest!
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