Family Application
Pre-registration is required. Please complete and submit the registration form by September 12, 2026.
Our Hospice is proud to be sponsoring and delivering Camp Eva 2026. Camp Eva is a half-day camp for children who are 5 to 12 years old and have experienced the death of a significant person or persons in their lives. Camp Eva provides a structured and supportive environment for children to openly share their feelings and memories of their loved ones. Camp Eva will offer activities and times of sharing which will allow the children to take home new and healthy ways of coping with their feelings and loss. It is the goal of Camp Eva to provide a safe place for expression of feelings through fun and age appropriate activities.
There is no cost to families for the camp.
Please complete the following application in full. There will be a follow up contact and family meeting with Our Hospice as needed to ensure Camp Eva is a good fit for each child. Please return the completed applications to, Melissa Clark, Camp Eva Coordinator, 2626 E. 17th Street, Columbus, IN 47201 or via email: campeva4kids@gmail.com. Please contact Melissa with any questions or call 812-603-6827.
We look forward to meeting you and your child!
Sincerely,
Melissa Clark
Founder of Camp Eva
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Child's Information:
Name:
Nickname:
School grade as of August 2026:
Age:
Birth Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
School Attends:
Gender:
Female
Male
Has this child attended any other grief camp or support group?
Yes
No
Please select your child's T-shirt size : Youth:
XS
S
M
L
XL
Adult:
XS
S
M
L
XL
Parent/Guardian Information:
Parent/Guardian Name:
Relationship:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Email:
example@example.com
Emergency Contact: (preferably other than that listed above
Emergency Contact Name:
Relationship:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Bereavement History:
Please include as much information as possible and add extra pages if necessary.
Name of the person who died:
Date of Death:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship of this person to the child:
Cause of death?
How old was the child at time of the death?
Where did the death occur?
Was the child present at the time of the death?
Did the child attend funeral or memorial services?
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Bereavement History continued
How did your child react to the death and experiences of the services?
Has your child received counseling in any form for grief?
Yes
No
If yes, please provide the name of the counselor and duration of services:
What signs of grief have you seen from your child?
Have you noticed any behavior changes in your child since the death?
Any other significant life changes for your child? (re-marriage, relocation, divorce, illness, loss of a pet, etc.)
How would you like your child to benefit from Camp Eva?
Do you give permission for your child to participate in pet therapy with a trained dog and approved volunteer?
Yes
No
Child's Medical History:
Please answer the following questions in full so that necessary preparations can be made as needed to best serve your child during the camp.
Are your child's immunizations up to date?
Yes
No
Please attach a copy of the immunization records.
Any recent surgery/hospitalizations?
Any significant illness within last year?
Are there dietary restrictions/needs?
Food allergies and reaction to exposure?
Medication allergies and reaction to exposure?
Insect Sting allergies and reaction to exposure?
Other allergies or medical concerns?
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Medical History continued:
Does your child have any medical or physical limitations? Please describe:
Any behavior concerns?
Any emotional concerns?
Does your child need assistance with toileting or personal hygiene?
Weight:
Height:
Primary Care Physician:
Phone Number:
Format: (000) 000-0000.
Please provide any other medical or physical needs information that the camp staff should know:
Please list all medications and dosages: (Camp staff will not be able to administer any medications)
Does your child have health insurance?:
Yes
No
Insurance carrier:
Policy Holder:
All of the application information will be reviewed by Our Hospice of South Central Indiana, Inc. and a nurse who is volunteering during the camp.
Parent/ Guardian Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Our Hospice Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please complete and submit registration forms by September 12th, 2026.
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