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Reach- A Camp for Teens: June 2017
  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. Contact Name
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  11. Daytime Phone
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  12. Evening Phone
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  13. Cell or Other Phone
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  14. How did you hear about camp?
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  15.  
  1. List the names and ages of living brothers and sisters:
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  2. Who has died in your family? (relationship of the deceased to the camper - e.g. Father, Mother, sister, etc)
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  3. Relationship (of deceased) to the camper
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  4. Age(s) of person(s) who died
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  5. 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.
  6. Cause of death (include any important details such as who was with the person when they died)
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  7. Did the teen witness the death?
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  8. Did the teen live with the person who died?
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  9. Please describe their relationship.
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  10. Any specific concern or other pertinent information (inappropriate or aggressive behavior incidents, remarriage, etc)?
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  11. is the teen having any specific difficulty in school or in relationships with others?
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  12. If yes, please explain:
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  13.  
  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 for Reach - A Camp for Teens?
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  5. What are the camper's hobbies, interests, or special talents?
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  6. Has the teen been in any support groups or sought counseling?
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  7. If yes, please explain the type (such as art, music, etc)
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  8. Please describe your teen
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  9.  
  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. Parent or Guardian Name
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  2. Occupation
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  3. Relationship to camper (of the person who completed this form)
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  4.  
  1. I give my teen permission to (check all that apply):(*)





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  2. Does the teen know how to swim?
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  3. Does the teen need flotation devices?
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  4. 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.
  5. Type your full name in the box below to acknowledge agreement with above statement(*)
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  6. Captcha - help us combat spam(*)
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  7. When you are ready to submit, click the submit button one time. Because we are generating a detailed confirmation with your submission, it will take a little longer than usual to process your registration once you hit the submit button. Please be patient as your confirmation is generated.