Camp Erin West Virginia Youth Camper Application

Camp Erin West Virginia Youth Camper Application
Youth's Full Name

First NameLast Name
Youth's legal name (if different from above):
This is only for our internal records and will not be viewed by anyone by the camp administrators.
Age (as of September 12, 2026):
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender

Other
Youth's mailing address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Name

First NameLast Name
Does this youth share time between two or more addresses?:
If yes, please list additional mailing address(es) for youth:
Please list all household members, including their name, age, and relationship to the youth:
Is a parent/guardian of the participant an active, reserve, or National Guard military member of military veteran? If so, what branch?
Youth's t-shirt size:
Youth's demographics

The following questions are optional and not used to determine acceptance. This information is used to better meet the needs of the communities we serve, and combined data is used for grant and impact reporting to keep Camp Erin free of charge.
Youth's ethnicity/race (check all that apply):

Other
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.)
Youth's Bereavement History

Please include information about all significant deaths in the participant's life. If including more than one person, please keep the responses in the same order for each prompt.
Name(s) of person(s) who died:
Relationship(s) to youth (Person is the youth's...):
Was this person(s) a significant caregiver to the youth?:
If more than one person is listed, please share who was the significant caregiver:
What did the youth call their person(s):
Date(s) of death:
Age(s) of deceased at time of death:
What was the cause(s) of death:
What does the youth know about the death(s):
Was the deceased an active, reserve, or National Guard military member of military veteran? If so, what branch?
Did the youth attend the funeral/memorial service?
If yes, what were the youth's reactions to the event? If no, was there a reason they did not attend?
Do you and the youth talk about the person(s) who died?
Did the youth receive counseling/grief support before or after the death?
If yes, please specify service(s) received and length of service(s):
Describe the relationship between the youth and the deceased (i.e. saw each other every day; visit twice a year)
How do you see your youth experiencing and expressing their grief?
Has the youth experienced any other deaths? (i.e. pets, distant relatives, teacher, etc.)
If yes, please specify the death(s) and describe the impact on the youth:
Youth's mental & emotional needs
Has the youth exhibited any of the following behaviors in the last two months? (Check all that apply)

Other
Please provide more information about the behaviors checked above:
Does your youth have any diagnoses that would be helpful for us to know: (i.e. Autism, Depression, Anxiety, ADD/ADHD, etc.)?
If yes, please explain
This information will help us plan for proper support to help your youth have a positive experience at camp.
Describe any other changes/stressors in the youth's life (i.e. divorce, illness, moves, etc.)
Have you noticed a change in the youth's social behaviors or peer relationships?
If yes, please describe:
Has your youth's behaviors, things they have said or done, concerned you lately?
If yes, please describe:
Is your youth receiving any support at school for education or social emotional needs?
If yes, please describe
Are there helpful coping strategies used at home or school that would be helpful for our camp staff to know?
If yes, please share 1-3 coping strategies:
Has the youth ever been involved with the juvenile justice system?
If yes, check all that apply:

Other
If yes, please describe:
Is there any additional information you would like us to know about this yourth that would help them have a positive experience at Camp Erin? (You can also share this information during your family interview prior to participating in a camp program):
Contact Information
Parent/Guardian Name

First NameLast Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone:
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about Camp Erin?
Name of Parent or Legan Guardian:
Parent/Guardian Signature
Relationship to youth:
Date & Time
Interview date preference

Please state days and times preferred to conduct a remote interview before camp. Interview with camp staff is required prior to acceptance.
Interview date preference #1

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Interview date preference #2

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Interview date preference #3

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What times generally work best for you?:
Should be Empty:

Camp Erin West Virginia Youth Camper Application

Youth's demographics

Youth's Bereavement History

Youth's mental & emotional needs

Contact Information

Interview date preference