Myra’s Kids Foundation – Winter Camp 2026
Participant Registration - Winter Camp Dates: February 5 – February 7, 2027
Winter Camp Program
Winter Retreat Dates: Friday, February 5 – Sunday, February 7, 2027 - Participants will depart by bus on Friday at 4:00 p.m. from the designated location (details to be shared closer to the retreat). Caregivers may be asked to confirm key health and contact information prior to departure. The retreat will conclude on Sunday at approximately 1:00 p.m., with bus return to the same location. Additional details, packing list, etc., will be shared with registered families in advance of the retreat.
Important Information
After you submit your application, a member of our team will contact you to schedule a required intake interview. This conversation helps us understand your child’s needs and ensure a safe and supportive experience.We know that talking about loss can be hard. Our team is here to support your family with care and understanding. If you have questions or concerns, please reach out to corrie@myraskids.ca
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Key Details for Winter Camp 2027
I understand that Winter camp dates are Friday, February 5 – Sunday, February 7, 2027
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Agree
I understand that the winter camp program is offered in English. Notez que le programme est offert en anglais.
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Agree
I understand that registration is part of the application process, and that acceptance to Winter Camp will be confirmed after connecting with the Myra’s Kids Foundation team.
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Agree
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Participant Information
Family Name / Nom de famille
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Participant Full Name
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First Name
Last Name
Participant Birthday (DD/MM/YY)
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Participant Age at Winter Camp (Feb. 5, 2027)
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Please Select
12
13
14
15
16
17
18
19
Preferred Pronouns
*
Please Select
She/Her
He/Him
They/Them
Other / Self-Describe [Text box appears if selected]
Prefer Not to Say
School Name
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Current Grade / Age
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Please Select
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Age 18
Age 19
Age 20
Age 21
Have you attended Myra's Kids Programs in the Past?
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Yes
This will be my first time participating
Other
If yes, which ones?
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Parent / Guardian Information
Parent/Guardian #1 Name
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First Name
Last Name
Parent/Guardian #1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian #1 Email Address
*
example@example.com
Parent/Guardian #1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian #2 Name
First Name
Last Name
Parent/Guardian #2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian #2 Email Address
example@example.com
Parent/Guardian #2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
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First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Participant
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Are there any custody/access restrictions we should be aware of?
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Yes
No
Other
In the event of an emergency, if no parent, guardian, or designated emergency contact can be reached, I authorize MKF leadership to make any necessary decisions on my/our behalf.
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Agree
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Participant Experience and Preferences
Name for Lanyard
*
We print personalized lanyards for each participant. Please share how you would like your name to be displayed.
T-Shirt Size
*
Please Select
Youth XS
Youth S
Youth M
Youth L
Youth XL
Adult S
Adult M
Adult L
Adult XL
Adult XXL
Dietary Restrictions
*
None / No Dietary Restrictions
Vegetarian
Vegan
Gluten-Free
Dairy-Free / Lactose Intolerant
Nut Allergy / Tree Nut Allergy
Shellfish/Seafood Allergy
Halal
Kosher
Other
Is the participant comfortable around water? (There's an indoor pool at the retreat centre)
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Please Select
Yes
No
What is their swimming ability?
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Please Select
Non-Swimmer
Beginner (Requires close supervision)
Intermediate (Comfortable in shallow/deep water)
Advanced (Strong swimmer in various conditions)
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Medical and Dietary Information
Does the participant have any allergies
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No Known Allergies
Yes – Please Specify
We answered "Yes" above
Medicare Number
*
Upload a photo of your Childs medicare card (can be sent once application is completed)
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Family Physician Name
Family Physician Office Name
Family Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Does the participant have any medication for specific allergies?
Do any allergies cause anaphylaxis risk?
*
Please Select
Yes – At risk for anaphylaxis
No – Not at risk for anaphylaxis
Unsure / Unknown
Does the participant carry an epi-pen?
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Please Select
Yes
No
*If you selected yes, you will need to send 2 epi-pens with your child to camp*
Are the participants immunizations fully up to date?
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Yes, fully up-to-date
No, not fully up-to-date
Unsure
Does the participant have a history of sleepwalking?
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Please Select
Yes
No
Unsure
Medical History
*Please let us know below if your child has any medical conditions such as asthma, breathing problems, skin conditions, frequent or recurrent infections (UTI, ear infections), digestion problems, sports injuries, heart conditions, epilepsy, migraines, diabetes, bleeding problems (nose bleeds), vision difficulties, hearing difficulties, any other issue your child is followed regularly by a medical professional etc.
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Mental Health Profile Social & Emotional Needs
Please share any Mental Health/Behaviours you believe to be relevant
(Please list if your child has any mental health or behavioral concerns, including anxiety, depression, ADD/ADHD, etc.)
Does the participant currently receive psychological or social work support?
*
Please Select
Neither of us receive support
I receive support
My child receives support
Both of us receive support
N/A
If yes, please provide the following details: Name of the professional(s), Type of support provided, Frequency of sessions, Duration of support to date, Contact information for the professional(s), Any specific strategies, recommendations, or concerns shared by the professional that we should be aware of to better support your child and anything else relevant to this subject that might help us.
Does the participant have any behavioural challenges we should be ?
No
Yes (please specify if possible below).
Unsure / Not sure
Wrote "Yes" above
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Grief and Bereavement Context
Death and Loss Information - We know that talking about loss can be hard. We ask these questions so our team can better support each participant with care and understanding. You are welcome to share only what feels comfortable. All information is treated with care and confidentiality.
Name of the loved one(s) being remembered
*
Date of Death
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Cause of death
*
What was their relationship to the participant?
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Mother
Father
Grandmother
Grandfather
Aunt
Uncle
Sister
Brother
Other Family Member
Other
Please tell us about what death(s) the participant has experienced
Did the participant live with the person who died?
Please Select
Yes
No
How would you describe the participants relationship with the deceased?
Age of person who died
Age of participant when their person died
*
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Please Upload a Photo of your child's special person.
*
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Choose a file
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Is there anything else you think it would be helpful for us to know about?
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Photo, Publicity, and Liability Waiver
By participating in Myra’s Kids Foundation Winter Camp 2027, you acknowledge and agree that photos, videos may be taken and that content may be created during camp activities for use in promotional materials, publications, and social media. These images will be used to celebrate and share the magic of camp while maintaining sensitivity to our campers’ privacy. Should you have any concerns regarding this, please indicate so during the intake process.
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Agree
To better understand who benefits from our services, we are collecting demographic data about our campers’ families, as requested by our funders. This information will remain confidential and only be accessible to MKF Camp administrators. We may share aggregated, anonymous summaries with funders (e.g., “xx% of campers experienced the death of a father”) to protect privacy. Rest assured, no personal information will be disclosed, and your access to services will not be affected by your responses.
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Agree
How did you hear about Winter Camp?
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Consent
I acknowledge that filling out this application is the first step in our process and does not ensure admission into the program. A Myra’s Kids Foundation representative will be in touch to schedule an interview shortly after receiving this application.
*
Please Select
Accept
By submitting this form, I confirm that all the information provided is accurate to the best of my knowledge.
*
Agree
Name of Guardian / Person Signing the Application
First Name
Last Name
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