Camp Monarch - Camper Information

Bereavement History Form

PARENT/GUADIAN INFORMATION
Name of Parent/Guardian*

First NameMiddleLast Name
Relationship to Camper*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
Emergency Contact *
Full Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
CHILD INFORMATION
Name of child attending Camp Monarch*

First NameLast Name
Age*
Gender*
T-shirt size*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INFORMATION REGARDING DECEASED
Name*

First NameLast Name
Age of person who died*
Relationship to camper*
Date death occured*
Age of camper at time of loss*
Cause of death*
Briefly describe the relationship between the camper and the deceased:*
YesNo
Was the camper present at the death/present at funeral/memorial?*
Have there been any other changes or stressful situations in your child’s life such as divorce, illness, recent move, etc? Please describe:*
Has your child experienced any behavioral problems you believe may be related to death?*

Does your child have difficulty with any of the following areas? If yes, please explain:

Rows	Check if yes	Please explain
Sleeping?
Eating?
School?
Relationships?

Are there any language, disability, or other needs, family customs, or cultural aspects to your child’s grieving that we should be aware of?
Please use this space to provide us with any other information about your child that will be helpful in providing a supportive camp experience.
Page 1 of 6

Authorizations and Permissions
Name of child attending Camp Monarch*

First NameLast Name
Dear Parent/Guardian,

Please read all authorizations and permissions required and provide your initials or signature where indicated. Your authorization must be granted in order for your child to attend camp.
I hereby authorize Angela Hospice Home Care, Inc., and its staff to supervise and instruct my child in all Camp Monarch program activities, August 3-4, 2023. I am aware of the nature of the Camp Monarch activities and any brochure, flyer or announcement relating to such activities is expressly incorporated by reference into this document. I hereby give my unqualified permission for my child to participate in all camp activities, for which he or she may qualify under camp standards. I am aware that there are inherent risks in camp activities and particularly in situations that involve physical activity, there may be a risk of injury. I understand that Angela Hospice does not provide accident or health care insurance for my child and that I am responsible for this insurance. I understand that it is my responsibility to inform Angela Hospice of any and all physical limitations, liabilities or injuries involving my child, including without limitation, neck and back problems, recent surgery, allergies and any other medical situations.
In the event of emergency, I hereby authorize the staff of Angela Hospice to administer first aid and/or obtain emergency medical treatment [911] as determined by Angela Hospice staff, including as necessary transportation for such treatment. This treatment may include routine tests and x-rays. I understand that in the event of an injury or other medical problem, Angela Hospice staff shall make every effort to notify me or a person I have identified as an alternate contact person as soon as possible and, subject to the need in a particular circumstance, to make an immediate decision regarding any such first aid and/or emergency medical treatment. Angela Hospice staff shall refer all non-emergent decisions relating to the medical care of my child to me or my alternate contact person.
I understand that Angela Hospice shall not be responsible or liable for the loss of personal property or any consequence of personal injury sustained by my child. This includes, but is not limited to, personal injury or loss of personal property sustained while participating in off-site activities. I hereby do indemnify and hold harmless Angela Hospice Home Care, Inc., from any loss, claim, or expense [including attorney’s fees] incurred by Camp Monarch but not caused by its negligence, arising from the personal injury of or loss of personal property by my child during Camp Monarch.
PERMISSION FOR GRIEF COUNSELOR
M.S.W. grief counselors will be present to provide supportive services to the Camp participants. Except for emergency evaluations, parents or guardians need to provide consent in order for counselors to intervene with their child. By signing below, you are providing your consent for your child to speak with a grief counselor if he/she desires. This is not a “counseling session” or an “assessment” but it is intended to enhance the camp experience for your child. The counselors will be supportive listeners and provide an opportunity for your child to talk about his/her life experiences. If a mental health emergency were to arise, these counselors will be available to assess
the campers and advise camp personnel.
Parent/Guardian signature

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Today's Date

MonthDayYear
Name of Parent/Guardian*

First NameMiddleLast Name
Page 3 of 6

Camper Release of Liability

This signed release is required for Camp attendance.
I, as parent/guardian and on behalf of camper's name [my child] and for Myself, release and discharge Angela Hospice Home Care, Inc., its agents, employees, directors, volunteers, and officers from any legal responsibility and/or liability for any personal injuries or illnesses, sustained by my child, either physical or emotional, or injury to property, real or personal, whether injury is due to negligence or any other cause, which may occur while my child attends Camp Monarch, or which may arise in the future and/or may be related to my child’s attendance at Camp Monarch.
Initials*
PERMISSION FOR GRIEF COUNSELOR
M.S.W. grief counselors will be present to provide supportive services to the Camp participants. Except for emergency evaluations, parents or guardians need to provide consent in order for counselors to intervene with their child. By signing below, you are providing your consent for your child to speak with a grief counselor if he/she desires. This is not a “counseling session” or an “assessment” but it is intended to enhance the camp experience for your child. The counselors will be supportive listeners and provide an opportunity for your child to talk about his/her life experiences. If a mental health emergency were to arise, these counselors will be available to assess the campers and advise camp personnel.
Initials*
This document is binding on me, my heirs, executors, legal representatives, successors and assigns. The provisions hereof continue in full force and effect even after the termination of Camp Monarch. This document shall be governed under the laws of the State of Michigan. If any portion of this agreement is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
Parent/Guardian Signature

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Today's Date

MonthDayYear
Name of Parent/Guardian*

First NameMiddleLast Name
Page 4 of 6

Photograph - Media Consent Form
I hereby grant to Angela Hospice Home Care, Inc., and its legal representatives the right and unrestricted permission to use and publish photographs or video images of my child, or in which my child may be included, for any purpose authorized by Angela Hospice Home Care, Inc., including but not limited to: website use, editorial publications, broadcast media (radio, television), literature and advertising use. This grant includes the right to modify and retouch the images in the discretion of Angela Hospice Home Care, Inc., I understand that the circulation of such materials could be worldwide and there will be no compensation to me for this use. I understand that I will not be given the opportunity to inspect or approve the finished products or the advertising copy or the printed matter that may be used in connection therewith.[If I have submitted materials to Angela Hospice Home Care, Inc., I further consent to the use of these materials by Angela Hospice Home Care, Inc., or its associates in any like manner. In granting this permission to Angela Hospice Home Care, Inc., and its legal representatives, I am fully and without limitation releasing them from any liability that may arise from the use of these submitted images.]
YesNo
Name of child attending Camp Monarch*

First NameLast Name
Name of Parent/Guardian*

First NameMiddleLast Name
Parent/Guardian signature

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Page 5 of 6
Today's Date

MonthDayYear

Physician's Medication Order Form
Name of child attending Camp Monarch*

First NameLast Name
YesNo
If medication is to be administered at camp, a form is required to be filled out by the child’s parent or guardian, signed by the physician ordering medication, and returned to Camp Monarch.

The Physician's Medication Order Form will be emailed to you upon submission of this page.
Should be Empty:

Bereavement History Form

Camper Health History Form

Authorizations and Permissions

Camper Release of Liability

Photograph - Media Consent Form

Physician's Medication Order Form