Discovering Hope Camp Application
Camper Information:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian name:
*
First Name
Last Name
Relationship to child:
*
Home phone:
Please enter a valid phone number.
Cell:
*
Please enter a valid phone number.
Work:
Please enter a valid phone number.
Parent/Guardian email:
*
example@example.com
Emergency contact:
*
First Name
Last Name
Emergency contact phone:
*
Please enter a valid phone number.
Emergency contact relationship to child:
*
Who will be picking up the camper at the end of the day?
*
Bereavement History
Please provide the following details about the loss(es) your child has experienced.
*
Health History
This section will be kept on file in case of emergency
Child's height:
*
Child's weight:
*
May we give your child Acetaminophen (Tylenol), Ibuprofen (Advil), or apply sunscreen if needed?
*
Yes
No
Does your child have any allergies, dietary restrictions, or physical limitations? Please list:
*
Does your child have any emotional or behavioral problems you think staff should be aware of?
*
Indemnification Agreement
To the best of my knowledge, the above information is correct and accurate. I give my permission to the agents of Heart of the Cumberland to authorize emergency transport to Cookeville Regional Medical Center if necessary. I understand that Discovering Hope Camp is faith-based with the goal to help facilitate the bereavement process and to provide support for my child in expressing their feelings of grief. In consideration of the above-named child being granted permission by Heart of the Cumberland to attend Discovering Hope Camp, I, for myself and on behalf of my child, release and discharge Heart of the Cumberland, its agents, Staff, Board of Directors, Officers, and Volunteers from all claims, demands, actions and judgments, which I or my child ever had or now has or may have against Heart of the Cumberland for all personal injuries, either physical or emotional, known or unknown, and injury to property, real or personal, sustained by my child’s person or property during his or her negligence or any other fault. I understand that acceptance is based on application information and contingent on a required pre-camp meeting for campers/guardians.
By typing my name below, I acknowledge that I have read, understand, and agree to abide by the Indemnification Agreement outlined on this form.
Date:
-
Month
-
Day
Year
Date
Photography Agreement
This material will primarily be used without names listed for camp participants to have a record of their day and in presentations to the supporting individuals and organizations who make camp possible. The photos and videos may also be used for future media publicity for Heart of the Cumberland and Discovering Hope Camp, including but not limited to social media, websites, and promotional materials.
I give my child permission to be photographed and filmed during their participation in camp activities for the purposes outlined in this form.
Yes
No
Submit
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