Camp Healing Hearts Application

Adult Participants Attending*

Youth Participants Attending*

Family Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone

Home Phone

E-mail

In case of emergency, please contact:*

Will your family be staying overnight at camp?*

YesNo

How did you find out about Camp Healing Hearts?

There is no cost to attend camp, but you must confirm your attendance. Kaleidoscope Grief Center will cover lodging and meal cost for each participant. Due to these costs, we ask that all cancellations be made by May 1, 2026.

Please include as much information as you would like.

It helps us identify needs unique to your family's loss.

Type a question*

Place of Death

Cause of Death

Please explain how the death of your loved one has afftected your family (changes in roles, environment, lifestyle, overall functioning and ability to adapt):

On a scale of 1 (poor) to 5 (excellent), how well do you think you and your family are coping with the death of your loved one?

Please summarize any additional stressors, losses, or changes that your family has recently experienced (i.e., divorce, marriage, relocation, illness, death of pet):

What benefits do you hope to obtain from attending Camp Healing Hearts?

Health History and Medical Information

Please complete for your family. All information obtained will remain confidential and only available for Camp use limited to staff and trained volunteers. Please use box at the end of this section if you need to provide additional medical information.

Participant Information*

Please add any additional information we need to know to provide a safe enviromment for you and your child(ren):

Medications

Please be sure to bring any medication that the participant may require including asthma inhalers, insulin and syringes, prescription medications, etc.

To the best of my knowledge, the above information is correct and accurate. I give permission to agents of Camp Healing Hearts to administer first aid to me and/or my child(ren), and I authorize emergency transport to the nearest acute facility.

Do any of the adult or youth participants have any physical, medical, or mental health conditions that could impact their ability to participate in any aspect of camp?

If yes, please explain below and include participants' names and details:

Do you have any serious concerns related to the youth's ability to stay overnight at CHH (ie: bedwetting, separation, anxiety, nightmares, etc)?

If yes, please explain below and identify youth that is affected:

By checking this box I am signing this document and confirming that it is accurate:*

Yes, I am signingNo, I am not signing

Family Application

Grief History