Camp Good Grief Application

  • MM slash DD slash YYYY
  • Is this the child’s first time attending Camp Good Grief?
  • Select the T-shirt size

  • Parent / Guardian Information

  • 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.


  • Is there anyone else permitted to pick this child up from camp?

  • Bereavement History

  • MM slash DD slash YYYY
  • Please enter a number from 0 to 99.

  • Medication Permission

  • Supervision

    Supervision is only provided during camp hours, not before or after. Camp hours are from 10:00 am to 2:00 pm. The adult dropping the child off must check in with staff and communicate who will pick the child up. At pick up, the authorized adult must sign out the child. If your child demonstrates unsafe or inappropriate behavior at camp, you (or the alternative contact if you can’t be reached) may be contacted to pick up the child.

  • Registration

    Please submit your registration early to avoid being put on a waiting list. Submit this registration form to Stein Hospice, Attn: Kathy Failor  1200 Sycamore Line  Sandusky, Ohio 44870

  • 2024 Provisions for Pandemic

    Camps registrations are limited for each camp.  First timers to camp will be given priority.  Cancelations of camps may occur if the pandemic is unstable at that time, notifications would be given. Masks may be required at camp drop off and pick up and possibly during certain times through-out camp day. Social distancing practices will be encouraged.

  • Parental Consent

    I give permission for my child to participate in Camp Good Grief, presented by staff and volunteers of Stein Hospice, an affiliate of Hospice of the Western Reserve. I understand that if the Group Facilitators have, or develop, concerns regarding the appropriateness of my child for this group, those concerns will be communicated to me. If necessary, recommendations or referrals to other counseling professionals will be explored.

  • Photo and Media Release

    I (the undersigned) hereby grant permission to Stein Hospice and Hospice of the Western Reserve to use my photograph/interview statements/video/story in publicity material and on its World Wide Web site or in other Stein Hospice publication or publications marketing the programs and services of Stein Hospice without further consideration. I acknowledge Hospice's right to crop or treat the content at its discretion. I also acknowledge that Stein Hospice may choose not to use my media materials at this time but may do so at its own discretion at a later date. I also understand that once my content is posted on Stein Hospice’s website, the image can be downloaded by any computer user. Therefore, I agree to indemnify and hold harmless from any claims the following: Board of Directors of Stein Hospice, an affiliate of Hospice of the Western Reserve, Stein Hospice and All Employees and Volunteers of Stein Hospice Stein Hospice reserves the right to discontinue use of media materials without notice.
  • 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).
  • Type your child's name.

  • Acknowledgement

    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.

  • Select Today's Date
    MM slash DD slash YYYY