Camp Good Grief | Stein Hospice

Dear Parent/Guardian:

We are looking forward to another great year at Camp Good Grief. Camp is open to children ages 6 through 13 who have experienced the death of a loved one. Our 2023 dates and locations are:

June 12 – 15 at Osborne Park in Huron
July 10 – 13 at Lakeview Park in Port Clinton
July 24 – 27 at Veteran’s Memorial Lake Park in Norwalk

Please complete one Camp Good Grief application and bereavement history form for each child. Once we have received and reviewed your child’s application, we will contact you to let you know if your child has been accepted and provide you with further details to assist you in preparing for camp. Space is limited and preference may be given for first time campers. Please contact bereavement coordinator Kathy Failor at 419.625.5269 or kfailor@steinhospice.org if you have any questions.

Sincerely,
Karen Hatfield
Director, Western Reserve Grief Services

Camp Good Grief Application

Name*
First Last
DOB*
MM slash DD slash YYYY
Age at Camp*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
First Time Attending*
Is this the child’s first time attending Camp Good Grief?
Camp to Attend*
Gender*
T-Shirt Size*
Select the T-shirt size
Allergies
Dietary Restrictions
Bee Sting Reactions*
Parent / Guardian Information
Parent / Guardian Name*
First Last
Relationship to Camper*
Parent / Guardian's Phone Number*
Parent / Guardian's Alternate Phone Number
Parent / Guardian's Email Address
Alternate Contact Information

An Alternative Contact is an adult authorized to pick-up / drop off child.

**Individuals dropping off and picking up children should be prepared to show identification if requested.

IN AN EMERGENCY, THE CHILD WILL BE TAKEN TO THE NEAREST HOSPITAL
Alternate Contact Name
First Last
Alternate Contact Relationship to Camper
Alternate Contact Phone Number
Is there anyone else permitted to pick this child up from camp?
Additional Alternate Contact Name
First Last
Additional Alternate Contact Relationship to Camper
Additional Alternate Contact Phone Number
Bereavement History
Name of Deceased
First Last
Approximate date of death
MM slash DD slash YYYY
Cause of death
Deceased age at death
Relationship to child (i.e., parent, grandparent, sibling, etc.)
Age of child at the time of the death
Please enter a number from 0 to 99.
Where did this person die (i.e., home, hospital, hospice facility, etc)?
Was the child present at the time of the death?
Did the child attend calling hours?
Did the child attend the funeral?
Has your child received professional grief support?
Please check all that apply to the child's mood/behavior in the past 3 months.
- anger
- sadness
- guilty feelings
- fear
- regrets
- worry
- anxiety
- hopelessness
- loneliness
- withdrawl
- nightmares
- separation anxiety
Please describe areas checked above
Is this child taking any medication related to mood or behavior?
If yes, please list
Please describe other significant changes/stresses in this child’s life that may come up during his/her time at camp (ex., other deaths including pets, divorce/separation, illness, loss of friendship, parent’s loss of employment, etc.).
How does this child get along with other children?
What else should we know about your child?
Please ask your child what he/she is looking forward to at Camp Good Grief.
Medication Permission
Child's Name
First Last
Date of Birth
MM slash DD slash YYYY
Medication(s) needed at camp:
Potential side effects of medication(s):
Please call me immediately if:
I give my permission to Stein Hospice staff at Camp Good Grief to administer my child’s medication(s) as needed during camp.
I give my permission to Stein Hospice staff at Camp Good Grief to observe my child self-administer medication(s) as needed during camp.
Parent Signature (type full name as signature):
Enter today's date (medication permission)
MM slash DD slash YYYY
Media Release Form

Images from Camp Good Grief (including camper artwork) will be used for camper activities, souvenir pictures, documentation of 2023 camp, and educational/promotional materials.
I / we, the undersigned, hereby consent to the use of the name of the individual below by Stein Hospice an affiliate of Hospice of the Western Reserve, Inc., or its designees.
I / we, the undersigned, hereby consent to the making of photographs, motion pictures, videotapes and audiotapes of the person named below by Stein Hospice an affiliate of Hospice of the Western Reserve, Inc., or its designees.
I / we understand that the material will be used for editorial, news, educational and/or promotional purposes to further the goals of Stein Hospice an affiliate of Hospice of the Western Reserve. Material may also be used by other institutions or professional groups for education with authorization from Stein Hospice.
I / we, the undersigned, hereby consent to the use of the name, images and story about the individual below on Stein Hospice an Hospice of the Western Reserve, Inc. online properties including but not limited to the website (hospicewr.org), Facebook (facebook.com/hospicewr), Twitter (twitter.com/hospicewr), YouTube (YouTube.com/HospiceWReserve) and LinkedIn.
Name of Individual
First Last
Signature (enter your full name as signature):
Relationship to individual if not self
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Enter today's date (media release)
MM slash DD slash YYYY
Participant Waiver
By signing below, I agree that my child (type name below), may participate in all Camp Good Grief activities at the location and dates below (choose one).
Child's Name*
Type your child's name.
Camp*
I understand that participation in the Program constitutes certain risks, and that injuries may occur. I voluntarily, knowingly, and intelligently recognize and accept any risk and agree to release from liability and to indemnify and hold harmless Stein Hospice/Hospice of the Western Reserve, its agents, assigns, or successors from all liability or claims, demands, damages and costs for or arising out of my participation in the Program whether caused by negligence or otherwise.

I have read this waiver and understand all its terms.
Date*
Select Today's Date
MM slash DD slash YYYY
Parent / Guardian Name*
First Last
Type your name as Parent / Guardian signature*

Camp Good Grief Application

Parent / Guardian Information

Alternate Contact Information

Bereavement History

Medication Permission

Media Release Form

Participant Waiver