Camp Erin NYC Camper Application 2024
Please do not skip any questions. This helps us best support each camper!
Camper full name
*
First Name
Last Name
Camper's preferred name at camp
*
Camper's Grade for the upcoming 2024-2025
*
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
Camper's Gender
*
Camper's Preferred Pronouns
*
She/Her
He/ Him
They/ Them
She/They
He/ They
Prefer not to say
Other
Camper's Date of Birth
*
-
Month
-
Day
Year
Date
Camper's Age at Camp
*
Camp begins August 23, 2024
Guardian Information
Guardian's Full Name
*
First Name
Last Name
Guardian's Relationship to Camper:
*
Mother
Father
Brother
Sister
Step-Mother
Step-Father
Uncle
Aunt
Grandmother
Grandfather
Cousin
Friend
Court Appointment Guardian
Other
Guardian's Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian's Telephone
*
Please enter a valid phone number.
Guardian's Email Address
*
example@example.com
Emergency Contact 1
*
First Name
Last Name
Emergency Contact 1: Relationship to Camper
*
Mother
Father
Brother
Sister
Step-Mother
Step-Father
Uncle
Aunt
Grandmother
Grandfather
Cousin
Friend
Court Appointment Guardian
Other
Emergency Contact 1: Phone Number
*
Please enter a valid phone number.
Emergency Contact 1: Email
*
example@example.com
Emergency Contact 2
*
First Name
Last Name
Emergency Contact 2: Relationship to Camper
*
Mother
Father
Brother
Sister
Step-Mother
Step-Father
Uncle
Aunt
Grandmother
Grandfather
Cousin
Friend
Court Appointment Guardian
Other
Emergency Contact 2: Phone Number
*
Please enter a valid phone number.
Emergency Contact 2: Email
*
example@example.com
Demographics
This information is used for Grant applications for Camp Erin NYC. Please do not skip questions.
How did you learn about Camp Erin NYC
*
Hospice
Grief Support Group
Physician/ Physician Assistant/ Nurse Practitioner/ Nurse
Psychologist/ Psychiatrist/ Counselor/ Social Worker
Newspaper/ Internet Search
Friend
Camp Erin Alumni
Camp Erin Volunteer
Cope Foundation
Other
Has your camper attended Camp Erin NYC before?
*
Yes
No
Does your child qualify for free and reduced lunch?
*
Yes
No
N/A
What languages are you capable of speaking fluently?
*
Spanish
Mandarin
Haitian Creole
English
Other
Camper's Ethnicity & Race
*
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White, Non-Hispanic
Other
N/A
Household Income
*
Less than $20,000
$20,000-$34,999
$35,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$149,999
$150,000-$199,999
$200,000 +
N/A
Does the guardian of the camper have military affiliation (Active Duty, Reserve, National Guard, or Retired)?
*
Yes
No
N/A
If yes to military affiliation: What branch of service?
*
Army
Air Force
Space Force
Navy
Marines
Coast Guard
Bereavement History
For camper- please do not skip questions this helps us best meet the needs of each camper.
Name of Deceased
*
First Name
Last Name
Was the deceased a known caregiver?
*
Yes
No
Relationship of deceased to camper
*
Mother
Father
Brother
Sister
Step-Mother
Step-Father
Uncle
Aunt
Grandmother
Grandfather
Cousin
Classmate
Friend
Other
Date of death
*
-
Month
-
Day
Year
Date
Age of deceased at time of death
*
Age of camper at time of death
*
Was the death anticipated?
*
Yes
No
What was the deceased's cause of death? (Please note this question is very important as we try to have increased commonality in our groups to ensure no camper feels alone in their grief.)
*
Natural
Accident
Suicide
Homicide
Accidental Overdose
Cancer
Cardiac
Covid-19
Motor Vehicle
Longterm Substance Use Disorder
Drowning
Military
Illness
Sudden
Other
Was the deceased in the military?
*
Yes
No
If yes to military affiliation: What branch of service?
*
Army
Air Force
Space Force
Navy
Marines
Coast Guard
N/A
Is your camper aware of the facts regarding the deceased's death?
*
Yes
No
Please share your campers understanding of the death.
*
This information is helpful to understand how your camper may do in grief related activities at Camp Erin NYC.
Where did the deceased die?
*
Is this your camper's first experience with death?
*
Yes
No
Was your camper present at time of death?
*
Yes
No
Did your camper see the deceased after the death?
*
Yes
No
Did your camper attend a funeral, celebration of life, or memorial service for the deceased?
*
Yes
No
Prior to the death, did your camper live with the deceased?
*
Yes
No
How would you describe your family's communication style?
*
Open
Adequate
Very Limited
Avoidant
Does your family do anything to honor the deceased throughout the year. Examples may include: birthday, holidays, etc.
*
Does your camper speak openly about the deceased?
*
Yes
No
When prompted by an adult
Sometimes
With friends
How would you describe your child's coping skills? (Coping skills are activities, experiences, or hobbies that help your child move through their emotions and grief).
*
Please check your camper's reactions to the deceased
*
Lack of energy
Withdrawn/ Isolation
Depression
Active suicidal ideations (within the last 3 months)
Past suicidal ideations
Active self harm (within the last 3 months)
Past self harm
Lack of interest in previously enjoyable activities
Sexual Behavior
Increase Fears
Sadness
Behavioral struggles at school
Academic struggles at school
Behavioral struggles at home
Current runaway behaviors (within last 3 months)
Past run away behaviors
Somatic symptoms: headaches, stomachaches, dizziness, nausea, increased aches.
Sleep walking
Bedwetting
Night Terrors (No Recollection of being upset in their sleep)
Nightmares
Night sweats
Fear of sleeping alone
Belief that death was their fault
Belief that death is a punishment
Decreased school attendance
Weight gain (unintentional)
Weight loss (unintentional)
Peer Difficulties
Drug use
Alcohol use
Increase risk taking behavior
Intentional harm towards others
Lying
Stealing
Destruction of property
Anger
Disbelief
Increase perfection
Increase control
Mixed emotions
N/A
Other
Please elaborate on your child's reactions (listed above).
*
Has your camper received professional support for their grief (school counselor, mental health therapist, peer support group, psychiatrist, pastoral support)?
*
Yes
No
Is your camper currently receiving professional support for their grief/ mental health needs (school counselor, mental health therapist, peer support group, psychiatrist, pastoral support)?
*
Yes
No
On a waitlist
If your child is currently receiving mental health, please elaborate on the support focus.
*
What else is helpful for us to know about your camper? (hobbies, interests, personality traits)
*
Does your camper have any known triggers?
*
Yes
No
Unknown
How can Camp Erin NYC help support your camper if a trigger is present and or arises?
*
Has your camper experienced any additional changes or stressors within the last year? (please check all that apply)
*
Moved Homes
Birth of a sibling
Adoption of a sibling
Loss of contact with a sibling
Change in family living situation
Death of pet
Moved schools
Divorce
Domestic Violence
Friends moving
Parent/Guardian change in Job(s)
Court case
Change in primary custody of child
Financial Stress
Serious or terminal illness
N/A
Other
Please elaborate on the changes your camper has faced within the last year.
*
Camper Information
Name and gender of siblings attending Camp Erin (please write N/A if needed)
*
T-Shirt Size
*
YOUTH small
YOUTH medium
YOUTH large
YOUTH XL/ Adult small
Adult small
Adult medium
Adult large
Adult XL
Adult XXL
Has your camper ever attended a day camp?
*
Yes
No
Has your camper ever attended an overnight camp?
*
Yes
No
Has your camper ever spent the night away from home?
*
Yes
No
Please indicate your camper's swimming level
*
Beginner
Intermediate
Advanced
Unknown
Does your camper enjoy music?
*
Yes
No
Does your child enjoy playing sports?
*
Yes
No
Does your child enjoy arts and crafts?
*
Yes
No
Please share about your camper's hobbies and interests.
*
To help us best support your camper please mark that all that apply regarding their personality:
*
Quiet, Reserved
Talkative
Active
Calm
Sensitive
Holds in emotions
Slow to warm up to people
Worrier
Easy going
Likes group activities
Likes group activities, but can be over stimulated
Does not like large group activities
Prefers one on one connections
Prefers adult connection over peers
Easily frustrated
Demonstrates leadership qualities
Night owl
Seeks control
Follows peers
Tires easily
Angry
Sad
Withdrawn
Happy
Overstimulated by loud activities
Overstimulated by large group activities
Please elaborate on your child's personality, and how Camp Erin can best support campers?
*
What can help ensure your camper has a positive experience at Camp Erin?
*
What concerns do you have about your child attending Camp Erin?
*
Is your child aware you have registered them for Camp Erin?
*
Yes
No
What concerns does your child have about Camp Erin? If no concerns please write N/A
*
Camper Medical History
Camper's Physician's Contact Information (Name, Practice Name, Telephone number)
*
Does your camper have a history of the following? (please check all that apply)
*
Physical limitations
Food allergies
Dietary restrictions
Asthma (please describe plan below and bring peak flow meter to camp)
Other allergies
Epilepsy/ Convulsions/ Seizures
Diabetes (please describe correction dose and medical protocol)
Chronic Ear Infections
Hearing Impairment
Motion Sickness
Nose Bleeds
Glasses or Contacts
Fainting
Heart Disease
Reoccurring headaches or stomachaches
Sleep walking/ nightmares/ night terrors
Bed wetting
History of serious illness (please describe further below)
History of homesickness
ADHD
Autism Spectrum Disorder (ASD)
Obsessive Compulsive Disorder (OCD)
Sensory Processing Disorder
Generalized Anxiety Disorder (GAD)
Depression
Post Traumatic Stress Disorder (PTSD)
Burn
N/A
Other
If you checked any boxes above, please elaborate (including medical protocol if applicable, medication dose, history, and plan for Camp Erin NYC to provide support)
*
Will your camper be taking any medications at Camp Erin?
*
Yes
No
(Medication 1): If your child will taking medication, please list the following: Medication name, the reason for medication, prescriber name, dosage, side effects, time of day taken
(Medication 2): If your child will taking medication, please list the following: Medication name, the reason for medication, prescriber name, dosage, side effects, time of day taken
(Medication 3): If your child will taking medication, please list the following: Medication name, the reason for medication, prescriber name, dosage, side effects, time of day taken
Are your camper's immunizations up to date?
*
Yes
No
Date of your camper's last tetanus shot?
*
-
Month
-
Day
Year
Date
Are there any other medical that your child has experienced or is currently experiencing that Camp Erin NYC should be aware of?
*
Does your camper have a known medical and or mental health diagnosis? If yes, please elaborate on your child's mental health diagnosis and the best way to support them at Camp Erin.
*
I attest that all information provided to Camp Erin NYC is accurate. Please type first and last name
*
First Name
Last Name
Thank you for completing your application for Camp Erin 2024. Please watch for an email from Stephanie Heitkemper (Stephanie@copefoundation.org), for scheduling your camper(s) Camp Erin interview. For any questions regarding Camp Erin NYC 2024, please email Ann Fuchs, Director of Camp Erin NYC at afuchs@copefoundation.org
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