2025 Camp Memiki

Fall 2025 Camp Memiki

Children's Grief Camp
Saturday, September 27, 2025

Ouabache Trails

3500 Lower Fort Knox Rd.

Vincennes, IN 47591

PLEASE SUBMIT BY SEPTEMBER 12, 2025
CHILD'S INFORMATION
Name of Child*

First NameLast Name
Age*
Grade in School*
School
Teacher's Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
T-shirt Youth or Adult*

YouthAdult
T-shirt size*

SmallMediumLargeX-Large
Home or Cell Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACTS
Emergency Contact 1*

First NameLast Name
Emergency Contact 1 Phone Number*
Relationship to Child*
Emergency Contact 2

First NameLast Name
Emergency Contact 2 Phone Number*
Please enter a valid phone number.
Relationship to Child*
RELATIONSHIP INFORMATION
Significant person/s who has died in the child's life and their relationship:*
Please describe the loss your child has experienced and how it has impacted them:*
Circumstances of Death:*
Date of Death*

MonthDayYear
Date
How do you hope the Grief Camp will benefit your child?*
Has your child attended grief groups in the past?*

Good Samaritan HospiceChurchSchoolOther
How was this helpful?*
Other changes, concerns or losses?
Food allergies/sensitivities*
Please list any medications your child is currently using*
PHOTOGRAPHY RELEASE

Good Samaritan Hospice reserves the right to take photographs or film any activity my child will be participating in during camp. I agree for these photographs or films to be used for promotional and/or commercial purposes.
Parental Name*

First NameLast Name
Parental Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Fall 2025 Camp Memiki

CHILD'S INFORMATION

EMERGENCY CONTACTS

RELATIONSHIP INFORMATION

PHOTOGRAPHY RELEASE