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Camp Lifetimes 2026
Participant information
Grief sharing and
education camp
First/last name:
First Name
Last Name
Age:
Gender:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School attending:
Grade:
Primary guardian information
Name:
Relationship:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred phone number:
Format: (000) 000-0000.
Alternate phone number:
Format: (000) 000-0000.
Email address:
example@example.com
Emergency contact information (other than guardian)
First/last name:
First Name
Last Name
Relationship to participant:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred phone number:
Format: (000) 000-0000.
Alternate phone number:
Format: (000) 000-0000.
Information regarding the person(s) who died
Name:
Age:
Birth date:
-
Month
-
Day
Year
Date
Date of death:
-
Month
-
Day
Year
Date
Died at:
home
hospital
hospice
work
other
She/He was my child's:
Causes/circumstances/location of death:
What other significant deaths have you experienced? Approximate date(s)?
Was your child involved in the burial, funeral, or memorial service?
Yes
No
Any concerns you have regarding your child?
-Turn Over-
Lory's Place
269.983.2707
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Camp Lifetimes 2026
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Date: June 17
th
Time: 9 a.m. to 3:30 p.m.
Ages: 5-11 (students who are entering kindergarten through fifth grade)
Drop off and pick-up will be at Lory's Place: 445 Upton Drive, St. Joseph, MI
Drop off time/registration: 8:30 a.m.
Camp will start promptly at 9:00 a.m.
Pick up time: 3:30 p.m.
Parents are welcome to attend the closing ceremony at Lory's Place from 3 to 3:30 p.m.
This year at Camp Lifetimes, Lory's Place honors the symbol of children's grief, the blue butterfly. The goal for Camp Lifetimes 2026 is to bring together kids who have experienced a death so they can better understand their grief, see that they are not alone, and learn how to mourn in healthy, meaningful ways. Our theme this year is Wings of Remembrance. Campers will explore the many emotions of grief through games, adventures, and creative activities that help uncover their bravery and unique strengths. Lunch will be provided.
Like the butterfly, we'll lift our wings and explore the world around us. Let's fly!
Insurance information: Is the participant covered by a hospital or health insurance plan?
Yes
No
If so, indicate carrier or plan name:
Group #
As authorized by my signature below, I affirm that I am the parent or legal guardian of the person listed on this form as Participant and that I am legally authorized to, and give consent on behalf of, the Participant to participate in the Camp Lifetimes summer programming events and activities, including transportation to (the "Program"). I authorize Lory's Place, to utilize any photographs, personal narratives, interviews, audio and/or video recordings of the Participant in any Lory's Place publications (paper and electronic) and events. In the event of Participant's illness or injury while attending and/or participating in the Program, I hereby consent to and authorize Lory's Place staff and volunteers to provide or secure medical treatment for the Participant and, if necessary, arrange for transportation to a medical facility. In the event I cannot be reached in an emergency, I hereby consent to the physician/provider selected by the event organizers to secure and administer medical treatment to the Participant. On behalf of myself, the Participant, and our heirs, executors, administrators, successors and assigns, I release, discharge, and hold harmless Lory's Place, its employees, officers, directors, and volunteers from any and all claims, demands, damages, and causes of action, whether the same are known or unknown, anticipated or unanticipated, resulting from, or arising out of, the Program on June 17, 2026.
Guardian name (identified above):
Signature:
Date:
-
Month
-
Day
Year
Date
Please return completed registration to Lory's Place by June 10,2026
Mail to: Lory's Place, 445 Upton Drive, St. Joseph, MI 49085 | Register online at: lorysplace.org
Space is limited. Register today!
This camp is free to attend. For more information call 269.983.2707 or visit lorysplace.org
Register online at:
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