2026 Camp Good Grief Registration / Health History Form

Camp Good Grief Registration / Health History Form
Name of Parent/Guardian

First NameLast Name
Phone
Relationship to Participant
To be completed by parents/guardians of the Camp Good Grief Participant. This form is confidential and to be kept with the participant's records.
Camper information
Name of Camper

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Notes for Camp Leaders
Camper t-shirt size*

Youth SmallYouth MediumYouth LargeYouth XLAdult SmallAdult MediumAdult LargeAdult XL
Address

Address

Street Address Line 2

CityState

Zip
Parent/Guardian Information:
Name*

First NameLast Name
Name

First NameLast Name
Phone *
Phone
Address (if different from the camper's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
- Consent to release
  
  List individuals who are authorized to pick up your child
- Name
  
  First NameLast Name
- Phone
- Relationship to Participant
- Name
  
  First NameLast Name
- Phone
- Relationship to Participant
- Name
  
  First NameLast Name
- Phone
- Relationship to Participant
- Breakfast, lunch, and a snack will be provided to your camper. Please indicate any allergies or dietary restrictions below.
- Food allergies and/or dietary restrictions
- My camper will bring their own breakfast/lunch/snacks*
  
  YesNo, my camper will eat the food provided by Centrica Journeys
- Physician’s Name*
- Phone*
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Do you carry family medical/hospital insurance?*
  
  YesNo
- If yes, please complete the following information:
- Insurance Company*
- Policy/Group #*
- Insured Name (parent)*
  
  First NameLast Name
- List of past medical treatments (if any)*
- List any current, physical, medical or psychological conditions requiring medical treatment or special restrictions or considerations*
- Allergies: Check those that apply, specify what reaction to look for and what treatments recommended*
  
  Penicillin/Other MedicationsFood AllergiesBee/wasp/insect bitesPlants poison ivy, etcAnimals dogs, horses, etcNoneOther
- MEDICATIONS
  Because the above-named participant requires medication during camp hours, I request that camp personnel be permitted to give this medication as directed below. I will provide the medication in an original pharmaceutically filled container whose label will clearly indicate the current and correct dosage, the physician’s instructions for administration and physician’s name. A physician’s letter with his/ her signature must be obtained prior to camp if the dose to be given at camp is different than that on the original container. This letter must include participant’s full name, dosage amount, delivery time(s), and any limitations. Do not repackage drugs or submit another person’s medication. This is Michigan law.
- Please list any medications taken on a regular basis (over the counter or/and prescription):*
  
  Name of medication / purpose Dosage(s) / time(s) to be administered
- Please list any medications taken on a regular basis (over the counter or/and prescription):*
  
  Name of medication / purpose Dosage(s) / time(s) to be administered
- Please list any medications taken on a regular basis (over the counter or/and prescription):*
  
  Name of medication / purpose Dosage(s) / time(s) to be administered
- Please list any medications taken on a regular basis (over the counter or/and prescription):*
  
  Name of medication / purpose Dosage(s) / time(s) to be administered
- Additional health conditions or limitations we should be aware of*
- Please list any activities the participant should be exempted from due to health reasons*
- PERMISSION TO SEEK MEDICAL TREATMENT
- I hereby give permission to the Camp Sponsor, its employees, personnel, nurses, volunteers, and agents (collectively, the “Camp Staff”) to seek, obtain and approve of any routine medical care and treatment for my child, who is the Camp Participant identified above, as reasonably deemed to be necessary or appropriate by such Camp Staff.
  
  Further, in the event I cannot be reached in an emergency, I hereby give the Camp Sponsor and the Camp Staff permission and authorization to seek, obtain and approve of any medical and/or surgical care and treatment, including, but not limited to, x-ray examination, anesthetic, medical, dental or surgical diagnosis, which may be recommended and provided under the general supervision of any physician or surgeon or other authorized and appropriate medical professional, for Participant, which in the reasonable judgment of such Camp Staff is necessary for the health and well-being of Participant during Participant’s participation in the Camp.
  
  Private insurance information must be provided, if applicable. I hereby authorize the Camp Sponsor and the Camp Staff to release all information, including the health information of my child and a copy of the Health Form, as necessary for such medical care and treatment and/or as necessary for managing the provision of health care at the Camp.
  - Please be advised that, should a participant require medical attention, the participant’s parent, or legal guardian (and not Centrica Care Navigators) is responsible for paying any costs not covered by insurance.
- Name*
  
  First NameLast Name
- Signature of parent/guardian*
  
  Clear
- Date*
  
  MonthDayYear
  Date
- RELEASE AND ASSUMPTION OF RISK
- In consideration for allowing the camp participant identified above (the “Participant”) to participate in the Centrica Care Navigators (the “Camp Sponsor”) Camp Good Grief (the “Camp”), I, as a parent and/or legal guardian of Participant, and on behalf of Participant, acknowledge and agree to all of the following: A. I authorize Participant to attend the Camp and participate and engage in any and all of the Camp activities. B. Prior to the commencement of the Camp, I was made aware of the nature of the Camp and had sufficient opportunity to inquire further. I understand the Camp has inherent risks and I assume, on behalf of Participant, full responsibility for all those inherent risks. (Parents and guardians who do not wish to accept the risks described in this warning should not sign this Form C. While participating in the Camp, Participant is subject to the policies, rules and regulations of the Camp Sponsor and the Camp. Possession of fireworks, explosives, any weapon, illegal drugs or alcohol is prohibited at the Camp and cause for immediate expulsion from the Camp. Further, any Participant repeatedly disobeying Camp or Camp Sponsor policies, rules or regulations may be expelled from the Camp. The Camp Sponsor is not responsible for lost or stolen property. D. I, on behalf of myself and Participant, release, indemnify and hold harmless Camp Sponsor, and its past, present and future shareholders, members, directors, officers, employees, agents, volunteers, donors, independent contractors and its and their successors, assigns and heirs (collectively, the “Indemnified Parties”) from and against any claims, liabilities, losses, damages and/or expenses (including reasonable attorney fees) arising out of the participation of Participant in the Camp, except to the extent caused by the sole gross negligence or intentional misconduct of the Indemnified Parties.
  
  ACKNOWLEDGEMENT
  By signing this Centrica Camp Good Grief Registration/Health Form, I, the parent or legal guardian indicated below, acknowledge that I have read and understand the above information and have completed such Form, and all other forms submitted on behalf of the Participant in connection with the Camp, fully and truthfully. The above agreements are binding upon me and the Participant, and our estates, heirs, representatives, and assigns.
- Name of parent/guardian*
  
  First NameLast Name
- Signature of parent/guardian*
  
  Clear
- Date*
  
  MonthDayYear
  Date
- For us to get to know your child(ren) better and to give them the best camp experience, we require a phone meeting with a parent or guardian prior to camp. Please give the best number to reach you and days and times that work for you to talk with a Grief Support Services Manager.
- Phone Number
- Days Available
- Time of day available
- To better serve and support your child, please complete this form.
- Name of person who died
- Relationship to child
- Date of Death
  
  MonthDayYear
  Date
- Cause of Death
- Did your child/children attend the funeral/memorial service?
  
  YesNo
- Was this person on Centrica Care Navigators services?
  
  YesNo
- Have there been other losses, multiple deaths, or life stressors (divorce, remarriage, move) your child
  
  YesNo
- If yes, please explain
- How does your child show they are grieving? (check all that apply)
  
  Sleep changesAnxietyCryingAppetite changesSadnessDenialHeadaches / Stomach achesGuiltIrritabilityAnger / Acting outOther
- As a parent or guardian, how do you address your child’s grief?
- Please explain any mental health or behavioral concerns of which camp staff should be aware
- Has your child received any professional support (i.e., social worker, school counselor, psychiatrist) If yes, for how long, and are they still receiving this support?
- If you feel your child has any special needs and/or requires special accommodations, please provide explanation
- Centrica Care Navigators offer Grief Support Services for our children and teens on the topics of death, dying and loss issues. Our services are educational and provide the opportunity for children to explore and better understand their feelings and thoughts associated with these topics. It is not the intention of our services to provide therapy. Instead, we offer education, companionship and support for children facing the uncertainty of loss and process of grief. We offer both individual and group sessions, as well as our annual Camp Good Grief for those experiencing a loss. *Please indicate if you agree to allow your child to participate in the Grief Support Services
- I Agree
- I hereby grant Centrica Care Navigators (hereinafter “Centrica”) and its associated entities the absolute right and permission to use and publish images in which I or my children may be included. I also consent to the extraction of information from any interview I might give. I understand that the images and interview information may be used in whole or in part, in conjunction with my own or a fictitious name. I waive any right that I may have to inspect or approve the finished product or products. I release, discharge, and agree to hold harmless Centrica, their legal representatives or assigns, and all persons acting under their permission of authority, from any liability in the use of photos or interviews, and understand that they may be used by Centrica without payment. I, the subject, or his/her legal representative, have read the above authorization, release, and agreement, and am fully familiar with the contents. These images/interviews may be used for news coverage, radio advertising, printed materials, direct mail, fundraising, internal/external website, YouTube, LinkedIn, Facebook, or Instagram. *Please indicate if you consent with the above Interview and Photograph Consent statement:*
  
  Yes, I consentNo, I do not consent
- Please complete the Girl Scouts Heart of Michigan Adventure Program Consent Form here before completing the rest of this form. Thank you!
- Type a question*
  
  Yes, I have completed and submitted the Adventure Program Consent Form
- Should be Empty:

Camp Good Grief Registration / Health History Form

Camper information

Parent/Guardian Information:

Consent to release

PERMISSION TO SEEK MEDICAL TREATMENT

RELEASE AND ASSUMPTION OF RISK