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Journeys: August 2017

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  1. You are registering for (*)
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  2. Camper's Name(*)
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  3. email(*)
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  4. Birth Date (*)
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    Type in the date (MM/DD/YYYY) or click calendar icon for pop-up, then click month to quickly change month and year as needed. Be sure to click on the day of the month to complete the date.
  5. Age
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  6. Address
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  7. City
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  8. State
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  9. Zip
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  10. Daytime Phone
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  11. Evening Phone
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  12. Cell or Other Phone
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  13.  
  1. Who has died in your family?
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  2. Relationship (of deceased) to the camper
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  3. Age(s) of person(s) who died
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  4. When did death occur?
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    Type in the date (MM/DD/YYYY) or click calendar icon for pop-up, then click month to quickly change month and year as needed. Be sure to click on the day of the month to complete the date.
  5. Cause of death (include any important details such as who was with the person when they died)
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  6. Did the person who died live with you?
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  7. What emotional and/or behavioral changes have you been experiencing since the death?
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  8.  
  1. List any health problems, dietary needs or limitations while at camp:
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  2. List any medications
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  3. List any allergies
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  4. What expectations do you have of the Journeys weekend?
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  5. What are your hobbies, interests, or special talents?
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  6. Please describe yourself:
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  7.  
  1. Optional - Responding to the following two questions is optional. However, responses to these questions is used to provide accurate statistics as required for grant applications and ensures that we are serving a diverse population. No personally identifiable information is given out.
  2. Gender
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  3. Please indicate race/ethnic origin







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  4.  
  1. Camper's T-shirt size





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  2. Desired name for camp name tag
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  3.  
  1. Emergency Contact Information
    Please provide the name and contact information of the person to contact in case of an emergency
  2. Emergency Contact Name
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  3. Relationship to you
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  4. Address
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  5. City
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  6. State
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  7. Zip
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  8. Daytime Phone
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  9. Evening Phone
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  10. Cell or Other Phone
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  11. Email
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  12.  
  1. I give my permission to (check all that apply):(*)




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  2. By typing my full name in the box below, I hereby release Stepping Stones of Hope in the case of injury. I understand and agree that Stepping Stones of Hope/Camp Samantha reserves the right to use camp photos and video for promotional purposes.
  3. Type your full name in the box below to acknowledge agreement with above statement(*)
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  4. Captcha - help us combat spam(*)
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