Camp Jamie Day Camp 2024 Application

Camp Jamie Day Camp

Dear Parent/Guardian,

Thank you for your interest in Camp Jamie, Day Camp. This Camp is for children, grades 1-8 who have experienced a significant loss in their lives. Unlike our original overnight camp, this camp is held for one day only. Enclosed you will find an application packet for Day Camp, which will be held on Saturday September 28th, 2024.

Please complete and return the entire packet no later than Friday September 13th, 2024 to 1 Frederick Health Way, Frederick, MD 21701 or email to griefsupport@frederick.health to be considered a camper. We will be conducting phone interviews to help with the referral process.

Camp Jamie Day Grief Camp will be held at Thorpewood Retreat Center at 13002 Mink Farm Rd, Thurmont, MD 21788. We ask that all campers arrive by 10:00 AM at the main lodge at ThorpeWood. Guardians are requested to return to ThorpeWood by 4:00 PM to have dinner and join your camper in our memorial closing ceremony.

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 children to express their grief. Through interactions with other children, adults, nature, and animals, the children experience the universality of loss and learn that they are not alone in their grief.

Licensed bereavement professionals, as well as trained 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 experience animal-assisted therapy designed to build self- confidence, teamwork, and trust. Many other recreational activities are built into this weekend, making it a real camp experience. The children will enjoy walking in nature, arts and crafts specifically designed to help them in their grieving process, and making s'mores around a campfire.

One day 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 of Day Camp is to lay the foundation of communication, knowledge, and coping skills, upon which families can continue to build.

Please feel free to contact us at 240-566-3030 or griefsupport@frederick.health if you have questions.

Thank you,
The Bereavement Team

E-mail address
example@example.com
Siblings (please list camper's siblings even if not attending camp):
Name Age
Has your child attended Camp Jamie in the past?

YESNO
If so, when?
Has your camper attended any bereavement camp in the past?

YESNO
If so, when and where?
PERSON TO CONTACT IN THE EVENT OF AN EMERGENCY
Name
Relationship to Camper
Daytime Phone:
Cell Phone:
Number of parents/guardians who will be attending the second half of camp (at 4 pm)
Name(s) and any dietary restrictions:

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

MonthDayYear
Date
Age of deceased at time of death
4. How did this person(s) die?
5. Was the child present at the time of death?
Explain circumstances
6. How did the child respond when they witnessed the death/received news of the death?
7. Did the child attend the funeral/memorial service? If no, why not?
8. Please explain how the child indicates that they are still grieving

9. Has the child received any professional support (i.e. psychologist, psychiatrist, school counselor, support group, etc.)? If so, how long was the professional support provided?
10. Has the child experienced any other deaths? If so, please explain:
11. Have there been any other changes/stressors in the child's life (i.e. divorce, illness, relocation, etc.) If so, please explain:

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

If you selected yes for any of the items in the BehavioralPhysicalMedical section please explain write the number of the item with the explanation
**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.

***If the child experiences any physical symptoms while at camp, a staff member

or volunteer will call their parent/guardian to discuss.

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 parentguardian

Clear
Date

MonthDayYear
Date

Camper 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
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 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 program to be held at the ThorpeWood property located in Thurmont, Maryland on September 28 , 2024 (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, and experiences with the farm animals 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.
Name of child
Signature

Clear
Date

MonthDayYear
Date
If the participant is under 18:
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date

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 the following exceptions:

1) Court-ordered subpoenas

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 agency that can ensure the safety and appropriate interventions for all concerned.
I understand the policy statement of Frederick Health Hospice's Bereavement Program regarding confidentiality and mandated reporting

MonthDayYear
Date
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. Physical limitations
11. Allergies
12. Asthma
13. Dietary restrictions
14. Convulsions/seizures
15. Diabetes
16. Frequent ear infections
17. Hearing impairment
18. Motion sickness
19. Nosebleeds
20. Wears glasses/contacts
21. Medications taken on a regular basis

Camp Jamie Camper Application

Bereavement History

About The Child