Camp Courage Registration Form

Name

First NameLast Name

Birth Date

MonthDayYear

Preferred Name

Age

Upcoming Grade

T-Shirt Size

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship to loved one who died, date of death, and circumstance of death:

Other significant changes in child's life (divorce, moving, other deaths or trauma, etc.):

Special religious or cultural considerations:

If your child is experiencing behavioral or other problems, please let us know. Does your child have a counselor or receive counseling services?

Pick Up Information

Name of person who will pick up your child.

Parent/Guardian Information

Name

First NameLast Name

Home Number

Format: (000) 000-0000.

Cell Number

Format: (000) 000-0000.

E-mail

example@example.com

Emergency Information

In case of an emergency, Camp Courage should notify:

Emergency Contact's Name

First NameLast Name

Relationship

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

Second Contact

First NameLast Name

Phone Number

Format: (000) 000-0000.

Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.

Medication

Please list all medications your child currently takes, including prescription medications, over-the-counter medications, vitamins, and supplements.

Nutritional Needs for Lunch (Vegan, Vegetarian, etc.)

If yes, please explain.

Allergies

If yes, please list out any food, medicinal, or environmental allergies.

Inhalers

If yes,

Medication Consent

I consent to the SECU Hospice House/ UNC Health Johnston Camp Courage nurse administering at his/her discretion Tylenol, Motrin, Ibuprofen, or Benadryl cream to my child for headaches, minor aches and pains, and ointment for cuts, scrapes, tec. And EPI pen will also be on site in the event of a severe allergic reaction.

Medication Consent:

Parent/ Guardian

Date

Camp Courage Consent and Transportation Consent Agreement

I give permission for my child to participate in Camp Courage. I give the SECU Hospice House/ UNC Health Johnston permission to provide medical care and to transport my child to the nearest medical facility in case of emergency. I understand that the SECU Hospice House/UNC Health Johnston may not be held liable in case of personal accident and/or injury, or of property loss or damage. I also understand that the camp will have outdoor adventure activities in which my child may potentially be exposed to but not limited to fire ants, insect bites, uneven ground when walking or running, splinters, scrapes and scratches, inflatable amusement games, sun exposure, and other physical activities.

I understand and agree to the cross-campus transport of my child as needed during Camp Courage. I acknowledge that the transport, including vehicle and driver, is provided on a volunteer basis and will be supervised at all times by camp personnel. I further understand that SECU Hospice House has arranged for the transport and has ensured the vehicle is licensed and insured in accordance with North Carolina regulations, and that the driver is appropriately licensed and qualified to drive.

Transportation Consent:

Parent/ Guardian

Date

Consent to Photograph

I hereby authorize SECU Hospice House/ UNC Health Johnston to take and use photographs of my child taken during camp activities for the purpose of promoting Camp Courage and the services of UNC Health Johnston Home Care and Hospice and the SECU Hospice House. I relieve and agree to hold SECU Hospice House/UNC Health Johnston free and harmless from any and all liability arising out of photographs and subsequent publications.

Photograph Consent:

Child's Name

Parent/ Guardian

Date

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date

Signature

Camp Courage Enrollment Form

Camper Information

Medication Dispensation Form