Camp Erin 2025 Camper Application

1
Camper's Full Name* This field is required.
First Name
Last Name
2
Camper's Date of Birth* This field is required.
Date
Year
Month
Day
3
Camper's Age* This field is required.
4
My camper should be placed in the following cabin:* This field is required.
Female
Male
5
Camper's Pronouns/Gender Identity (optional)
6
T-Shirt Size* This field is required.Select Camper/Child's T-Shirt Size
Please Select
Please Select
Adult Small
Adult Medium
Adult Large
Adult XL
Adult XXL
Adult XXXL
Child Small
Child Medium
Child Large
Child XL
7
Parent/Guardian Full Name* This field is required.
First Name
Last Name
8
Home Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Parent/Guardian Email* This field is required.
example@example.com
10
Best Number to Reach Parent/Guardian* This field is required.
Please enter a valid phone number.
11
Camper's Current School* This field is required.
12
Camper's Current Grade in School* This field is required.Choose most current grade completed
Please Select
Please Select
Kindergarten
1st Grade
2nd Grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
13
Is either parent/guardian an active, reserve, or national guard military member or military veteran?* This field is required.If yes, answer the next question. If no, enter NA in next question
YESNO
14
If answer to last question was yes, which branch of military is/did guardian/parent serve in?* This field is required.
15
Are there other campers in your family applying?* This field is required.
Please Select
Please Select
Yes
No
Names and Ages of additional campers applying
16
How did you hear about this program?* This field is required.
17
Has Child Ever..* This field is required.Check all that apply
Attended Day Camp
Spent the night away from home
Attended overnight camp
Attended Camp Erin before
None of the above
All of the above
18
Medical Information* This field is required.Select all that apply to your camper
Physical/developmental disability
Allergies
Takes prescription medication
Dietary restrictions
Not Applicable
19
Please expand on any selected medical needs* This field is required.List all medications/dosages and allergy/asthma plans, if not applicable "N/A"
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Ok
20
Emergency Contact* This field is required.Name, Relation, phone number
21
Full Name of Deceased* This field is required.
22
Relationship to Child* This field is required.
23
Date of Death and Age of Deceased at time of Death* This field is required.
24
Age of Camper at Time of Death* This field is required.
25
Was the death* This field is required.
Expected
Sudden
26
What was the deceased's cause of death?* This field is required.
27
Where did the deceased die?* This field is required.(i.e. home/hspice, hospital, elswhere)
28
Was the camper present at the time of death?* This field is required.
YESNO
29
Did the camper see the deceased after the death?* This field is required.
YESNO
30
How did your camper react to the death?* This field is required.
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31
Was the deceased an active, reserve or national guard military member or military veteran?* This field is required.
YESNO
32
If so, what branch?* This field is required.Enter N/A if this does not apply
33
Was there a funeral or memorial service?* This field is required.
YESNO
34
If yes, did your camper attend and what were their reactions/comments to the service?
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35
Did your camper live with the deceased?* This field is required.
YESNO
36
How would you describe your camper's relationship to the deceased?* This field is required.
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37
Was the deceased a significant caregiver to your camper?* This field is required.
YESNO
38
How does your family communicate regarding the deceased?
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Ok
39
Does your camper speak openly about the person who died?* This field is required.
YESNO
40
Please explain how your camper shows that they are grieving.* This field is required.
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41
Is this your camper's first experience with death?* This field is required.
YESNO
42
If no, please comment on other deaths your camper has experienced.
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Ok
43
Reactions to loss* This field is required.select all that apply to your camper
Anxiety
Lack of energy
Withdrawn, isolation
Depression
Suicidal thoughts/talk
Difficulty with concentration
Causing harm to self
Loss of interest in usual activities
Innappropriate sexual behavior
Special fears
Sadness
Worries about his/her safety or the safety of others
Hyperactive/Impulsive
Behavior problems at school
Behavior problems at home
Running away from home
Headaches, stomachaches
Insomnia
Sleep walking
Bedwetting
Nightmares
Night sweats
Belief that death was their fault
Belief that death is a punishment
Changes in attendance at school
Increase in weight
Decrease in weight
Peer difficulties
Drug/alcohol use
Causing harm to others
Lying
Stealing
Destruction of property
Anger
Disbelief
Always trying to be in control or perfect
Changes in how he/she feels about self
44
Did your camper receive professional support before or after the deceased's death?* This field is required.
YESNO
45
If so, check which apply
School counselor
Mental health therapist
Pastoral support
Peer support group
Psychiatrist
46
If so, when did camper start and end support?
47
Have there been any other changes/stresses in your child's life?i.e. illness, relocation, divorce, remarriage, finances, other losses?
Please Select
Please Select
Yes
No
If yes, please explain
48
Has your camper ever experienced abuse of any kind?* This field is required.
YESNO
49
If yes, please explain
50
Please describe your camper's personality/character traits?* This field is required.
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51
Is there anything we should be aware of to better serve your camper in these areas-Language, Disability, Religious Needs, Other?Answering this question is voluntary and will only be used to help your child with the grieving process.
52
Are there any other special needs, family customs, or cultural aspects to your camper's grieving that we should be aware of?
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53
Is your camper displaying any behaviors/moods that have you concerned?
Please Select
Please Select
Yes
No
If yes, please explain
54
Is your camper experiencing any difficulties sleeping at night?
Please Select
Please Select
Yes
No
If yes, how might this affect time at camp?
55
Does your camper enjoy...select all that apply
Expressive arts (acting, music, writing)
Physical activities
Arts/Crafts
Group Activities
Swimming/Water
56
Please list any special interests your camper has
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57
Have you and your camper discussed attending Camp Erin?* This field is required.
YESNO
58
Please list any preferences you have related to cabin assignments for your camper. Note: not all requests can be accommodated though we will make our best effort. * This field is required.
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59
Ethnicity of Camper* This field is required.Select all that apply
African American/Black
American Indian / Alaska Native
Asian
Hispanic / Latino
Middle Eastern / North African
Native Hawaiian / Pacific Islander
American Indian / Alaska Native
White
Multi-race
Another race not listed
Prefer not to share
Other
60
In the last year, did you or anyone in your family qualify for any government assistance programs?* This field is required.(i.e. free/reduced lunch, WIC, SNAP, housing assistance, Medicaid, SSI, etc.)
Yes
No
61
Name of Legal Guardian* This field is required.
First Name
Last Name
62
Relationship to Camper* This field is required.
63
Signature of Legal Guardian* This field is required.
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64
Date Signed* This field is required.
Date
Year
Month
Day
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