Camper Application 2024

Camp Erin Los Angeles 2025

Camper Application
We are currently accepting applications for Sunday, August 24th

Important Notes:

*A phone call and interview conducted by our clinical staff will be required after the completion of this application

*We ask that all campers be told by their caregiver about Camp Erin LA prior to their interview

* A separate application must be completed for each camper
This summer we are hosting two options for our day camp. Please mark the session you and your child(ren) would like to the attend:*

Session 1: Saturday, August 23rd (WAITLIST)Session 2: Sunday, August 24th
Camper's Name*

First NameLast Name
Camper's legal name (if different from above)
Camper's gender*

MaleFemaleNon-binaryOther
Camper's Pronouns (What words would your camper like us to use when not referring to them by name? ie. she/her, he/him, they/them, etc.)
Date of Birth (mm/dd/yyyy)*

MonthDayYear
Age of Camper by August 2025: *
Camper's Primary Language*
School*
Has your child participated in an OUR HOUSE Group?*

Yes, In the Family Support ProgramYes, In OUR HOUSE School Based GroupNo
Please describe the Camper's personality/character traits*
Has Camper attended Camp Erin LA before?*

YesNo
Which best describes the Camper's reaction to the possibility of attending Camp Erin LA?

ExcitedResistantUnsure/Mixed FeelingsOther
Has the Camper received any disciplinary action for behavior from school and/or a previous camp? If Yes, please explain.*

NoYes
Parent/Guardian Information

The day camp schedule includes an adult program that requires the participation of one parent/guardian per family. We will be providing adult programming separate from your camper's experience throughout the duration of the camp day. Adults will participate in a range of grief and fun activities, meet other camper guardians and witness the closing Luminary Ceremony of your campers. We require 1 guardian to attend camp.

Below please provide information regarding the accompanying guardian.
Accompanying Parent/Guardian Full Name: *

Parent/Guardian First NameParent/Guardian Last Name
Parent/Guardian Pronouns (ie. she/her, he/him, they/them, etc.)
Accompanying Parent/Guardian Relationship to Child: "I am the camper's _____"*

MotherFatherGrandparentAunt/UncleLegal GuardianOther
Parent/Guardian preferred language *
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Relationship to the deceased: "I am the _____ of the person who died"*

ParentGrandparentLegal GuardianPartner/SpouseEx-Partner/Ex-SpouseOther
How did you learn about Camp Erin LA? (please mark all that apply)*

OUR HOUSE Staff/Board MemberSchoolFamily Member/FriendFormer Camper/VolunteerMedical/Mental Health ProfessionalInternet SearchOUR HOUSE Newsletter/WebsiteOUR HOUSE Social Media"One Last Hug" DocumentaryOther
Household & Prospective Camper Health Information

Please note: this application must be completed by the camper's parent/legal guardian & a separate application must be submitted for each camper

Household Information:*

	Name	Age	Relationship to Camper
Household Member 1
Household Member 2
Household Member 3
Household Member 4

Prospective Camper Health Information: Please mark any of the following that apply to the camper: *

	Yes	No
Asthma
Convulsions/Seizures
Diabetes
Chronic Ear Infections
Hearing Impairment
Nosebleeds
Wears Glasses/Contacts
Recurring Headaches or Stomach aches
Other (we will ask you to specify)

Will the Camper be taking medications at camp? If yes, please list the medication and what they are treating.

	Name of medication	Dosage & Schedule	What is it treating?
Medication 1
Medication 2
Medication 3
Medication 4

Does the Camper have any history of operations or serious illnesses? If Yes, please explain.*

NoYes
Does the Camper have any special needs, physical limitations, diagnosed mental illnesses, and/or developmental/learning disabilities (IEP, OT services)? If Yes, please explain.*

NoYes
Does the Camper have any dietary restrictions or unique eating habits that we should be aware of? (physician recommended, religious, etc.) If Yes, please list below.*

NoYes
Does the Camper have any allergies? (to food, medicine, environment, bee stings, seasonal, etc.) If Yes, please list below.*

NoYes (Please note how this presents)

Emergency Contacts: Please list two local people other than the accompanying adult that we can contact in case of an emergency.*

	Name	Relationship to Camper	Phone Number
Emergency Contact 1
Emergency Contact 2

Bereavement & Family History

We understand that these questions may be difficult to answer. This information helps us to better support your Camper in their grief and provide the best possible care.

Please tell us about the significant person(s) the Camper is grieving:
First & Last Name of the Person Who Died *

First NameLast Name
Age of Person Who Died at Time of Death
Date of Death (mm/dd/yyyy)*

MonthDayYear
Date
What the Camper called their Person(s) Who Died
Camper's Age at Time of Person's Death *
Their Relationship to Child: "It was the child's ______"*

FatherMotherSiblingGrandfatherGrandmotherUncleAuntCousinFriendOther
Did the Camper live with the person who died and/or was a significant caregiver?*

YesNo (if no, please describe what kind of contact and how frequently the Camper was in contact with the person who died)
Cause of Death*

CancerHeart DiseaseSuicideMotor Vehicle AccidentHomicideOverdoseLong-term Substance UseNatural CausesStrokeDrowningMilitaryCOVID-19Accident- Not vehicleOther
Was the Camper present at the time of death?

YesNo
Has the camper been told the facts about the cause of death?*

YesNoOther
Please note: It is in your Camper's best interest to know the true cause of death. Therefore, it is a requirement of Camp Erin LA that Campers know the true cause of death, if it is known to the family. Camp Clinical Staff are available to assist you in having this conversation with your Camper and to provide clinical rationale for this requirement.
Please describe the type of relationship the camper had with their person who died.*
Is this the Camper's first experience with death?*

YesNo, please explain the other deaths the Camper has experienced, including (1) Who died (2) Date of Death (3) Cause of Death
Describe how the camper reacted to the death?
How would you describe the Camper's family's communication regarding the death?*

OpenAdequateMinimalAvoidedNone
Please describe how the Camper indicates they are grieving. (ie, open, avoidant..) *
Is the Camper displaying any behaviors and/or moods that concern you?*

NoIf Yes, please explain
Camper's Reaction to the Death

Please mark any of the following that the Camper has exhibited since the death(s) of their significant person(s).
Physical Changes*

Headaches/Stomach achesLack of EnergyEncopresisLoss of Interest in Usual ActivitiesIncrease in AppetiteDecrease in AppetiteDifficulty ConcentratingIncrease in sleepDecrease in sleepBedwettingNightmaresNight TerrorsSleepwalkingNone of these
Thoughts & Feelings*

AngerWorries About Safety/Death of self of othersTrying to Be Perfect or always in controlDepressionSadnessGuilt/RegretSuicidal Thoughts/TalkSpecial FearsSeparation/General AnxietyBelief the Death is a PunishmentDisbeliefChange in Self PerceptionBelief that Death was Their FaultWithdrawn/IsolatedHappy MemoriesNone of these
Behaviors*

Inappropriate Sexual BehaviorHyperactive/ImpulsivePeer DifficultiesLyingDestruction of PropertyRunning AwayCausing Harm to OthersStealingSelf-HarmChange in School AttendanceBehavior Problems at HomeDrug/Alcohol UseBehavior Problems at SchoolNone of theseSuicide Attempts* (if so, when?)
Has the Camper ever witnessed or experienced violence of any kind?*

NoIf Yes, please explain
Has the Camper ever been removed from their home due to abuse or neglect of any kind?*

NoIf Yes, is there currently an open case with the Department of Child and Family Services?
Is the Camper currently connected to psychosocial support/services?*

NoYes
If Yes, please mark all that apply:

School CounselingPsychiatryIndividual TherapyFamily TherapyPastoral SupportPeer Group Support or Group CounselingGrief CampPsychiatric HospitalOther
Please explain any family customs, religious/faith practices or cultural aspects to the Camper's grieving that we should be aware of to better support them.
Please upload a photo of your camper: *

Cancelof
Guardian's Name*
Guardian's Signature *

Clear
Date*

MonthDayYear
Date
Anything else you would like us to know about your camper?
Would you like to receive communication about OUR HOUSE Grief Support Center programs and events?*

YesNo
The questions in the following section are optional and is not used to determine acceptance. This information is used to better meet the needs of our community and gain critical funding.
# of People in Household
# of People in Household OVER Age 18
# of People in Household UNDER Age 18
Family Income

Less than $25,000$25,000 - $34,999$35,000 - $36,899$36,900 - $49,999$50,000 - $74,999$75,000 - $99,999$100,000 +Decline to Answer
In the last year, did you or anyone in your family qualify for any government assistance programs? (for example, free/reduced lunch, WIC, SNAP, housing assistance, Medicaid, SSI, etc.)

YesNo
Does the camper attend LAUSD?

YesNo
Camper Race/Ethnicity (please mark all that apply)

African American/BlackAsianCaucasianHispanic/Latino/a/xNative AmericanPacific IslanderMulti-Race/EthnicDecline to AnswerOther
Parent/Guardian Race/Ethnicity (please mark all that apply)

African American/BlackAsianCaucasianHispanic/Latino/a/xNative AmericanPacific IslanderMulti-Race/EthnicDecline to AnswerOther
Is the Camper's Parent/Guardian and/or the person who died affiliated with the military as active duty, reserve, or veteran?

NoDecline to AnswerIf Yes, Please share who and which branch
If you have any questions regarding Camp Erin LA, please contact Juliana Sanabria, Clinical Coordinator of Camp, at (310)-231-3186 or juliana@ourhouse-grief.org.

Consent to Release Information
(OUR HOUSE Grief Support Center Staff to Provider)

Signing this document authorizes OUR HOUSE Grief Support Center to communicate with your mental health (therapist or psychiatrist) or healthcare (medical doctor) provider regarding grief support groups and your interaction with OUR HOUSE staff. Should your safety and/or the safety of another be of concern, this consent is required to allow us to collaborate with your healthcare team to provide you the best care possible. Failure to provide all information requested will impede our ability to collaborate with those who know you best.
I consent for OUR HOUSE Grief Support Center to exchange information regarding my camper with my their therapist/healthcare provider and for my child's therapist/healthcare provider, to exchange information with OUR HOUSE Grief Support Center*

YesNoN/A
I consent for OUR HOUSE Grief Support Center to exchange information regarding my camper with my their therapist/healthcare provider. This consent allows OUR HOUSE Grief Support Center to release information regarding my child'sparticipation in group as well as interactions with agency personnel including, but not limited to my child's attendance to group sessions, behaviors and verbalizations regarding safety concerns and emotional states.

I consent for my child's therapist/healthcare provider, to exchange information with OUR HOUSE grief Support Center. This consent allows my child's Therapist/ Healthcare Provider to provide the following information: adherence to treatment including attending appointments, taking medications as prescribed, clinical risk assessments(including, but not limited to suicidality, homicidality and/or grave disability), participation in treatment planning, psychiatric hospitalizations and any other pertinent information that may impact group participation.

This consent expires one year from the date of authorization indicated by the signature at the bottom of this page
Name of therapist/healthcare provider:
Address of therapist/healthcare provider:
Phone of therapist/healthcare provider
Guardian's Name

First NameLast Name
Camper's Name

First NameLast Name
Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty: