Fall 2024 Camp Jamie Teen Grief Retreat Application

Camp Jamie Camp Jamie Teen Grief Retreat
Thank you for your interest in Camp Jamie, Teen Grief Retreat, Fall 2024. This camp is for teens, grades 9-12 who have experienced a significant loss in their lives. Enclosed you will find an application packet for camp, which will be held on Saturday, November 9, 2024.

Please complete and return the entire packet by October 25, 2024, to 1 Frederick Health Way, Frederick MD 21701, or scan and email to griefsupport@frederick.health to be considered as a camper. We will be conducting phone interviews to help with the referral process.

Camp Jamie Teen Grief Retreat will be held at ThorpeWood Retreat Center at 12805 Mink Farm Rd, Thurmont, MD 21788. We will be asking that all campers arrive by 9:30AM at the main lodge at Thorpe Wood. Campers will need to be picked up/leave by 7:30PM.

This one-day retreat is designed to gently teach coping skills and help build self-esteem and trust. It also offers a safe, comfortable environment for teens to express their grief. Through interactions with other teens, adults, nature, and animals, campers experience the universality of loss and learn that they are not alone in their grief.

Licensed and trained counselors, as well as trained staff and 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 also experience the Equine Assisted Learning Program designed to build self-confidence, teamwork, and trust. Many other recreational activities are built into the day, making it a real camp experience. Campers will alsoenjoy hiking, arts and crafts specifically designed to help them in their grieving process, and a remembrance ceremony around the campfire!

A day camp is just a small time frame, but we know we can truly make a difference in the life of a teenager, even in this short time period. The intention is to lay the foundation of communication, knowledge, and coping skills, upon which families can continue to build.

Please feel free to contact us if you have questions.

Sincerely,

The Hospice Bereavement Team

Parent/Guardians Name
Daytime Phone
Evening Phone
Email address
example@example.com
Siblings (please list teen's siblings even if not attending camp):
Name Age
Has your teen 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 Teen
Cell Phone
Cell Phone

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

MonthDayYear
Date
4. Age of deceased at time of death
5. How did this person(s) die?
6. Was your camper present at the time of death?
Explain circumstances

7. For campers bereaved by suicide overdose or homicide are they aware of the circumstances of the death? How was this information shared with them?
8. Did they attend the funeral/memorial service? If no, why not?
9. Please explain how they indicate that they are still grieving
10. Have they received any professional support (i.e. psychologist, psychiatrist, school counselor, support group)? How long was the professional support provided?

11. Have they experienced any other deaths? Please explain:
12. Have there been any other changes/stresses in their life (i.e. divorce, illness, relocation, etc.) Please explain:

If you checked 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.

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 Parent/Guardian

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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

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Date

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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

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Date

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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 agree, as part of the ____ Camp Jamie_______program to be held at the ThorpeWood property located in Thurmont, Maryland on November 9, 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

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Date

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

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Date

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

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Date
(Self/ParentGuardian)
Email
example@example.com
Should be Empty:

	YES	NO
1. Sleep disorder (i.e. sleep walking, bed wetting)
2. Eating disorders
3. Suicidal ideating/talking about wanting to die
4. Suicide attempts
5. Medication taken on a regular basis
6. Poor school attendance
7. Poor grades
8. Prior history of trauma
9. Lack of social skills
10. Difficulty getting along with peers
11. Difficulty getting along with adults
12. Difficulty getting along with family
13. Behavior problems
14. Physical limitations
15. Allergies
16. Asthma
17. Dietary restrictions
18. Convulsions/seizures
19. Diabetes
20. Ear infections
21. Hearing impairment
22. Vision impairment (including glasses or contacts)
23. Motion sickness
24. Nosebleeds
25. Mental health diagnosis
26. History of substance use (drugs or alcohol)
27. Autism Spectrum Disorder
28. Other

Bereavement History