Page 1 of 7

Camp Samantha Registration (Kids and Grown-Ups): July 2017 Note: (*) indicates a required field
  1. First, please tell us which camp you are registering for(*)
    (click on the appropriate camp in the box below)
    Invalid Input
  2. Camper's Name(*)
    Invalid Input
  3. email(*)
    Invalid Input
  4. Birth Date (*)
    Invalid Input
    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
    Invalid Input
  6. Address
    Invalid Input
  7. City
    Invalid Input
  8. State
    Invalid Input
  9. Zip
    Invalid Input
  10. Contact Name
    Invalid Input
  11. Occupation
    Invalid Input
  12. Daytime Phone
    Invalid Input
  13. Evening Phone
    Invalid Input
  14. Cell or Other Phone
    Invalid Input
  15. How did you hear about camp?
    Invalid Input
  16.  
  1. List the names and ages of living brothers and sisters:
    Invalid Input
  2. List the names and ages of children attending Camp Samantha:
    Invalid Input
  3. List the names and ages of children affected by this death who will not be attending Camp Samantha:
    Invalid Input
  4. Who has died in your family?
    Invalid Input
  5. Relationship (of deceased) to the camper
    Invalid Input
  6. Age(s) of person(s) who died
    Invalid Input
  7. When did death occur?
    Invalid Input
    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.
  8. Cause of death (include any important details such as who was with the person when they died)
    Invalid Input
  9. Did the person who died live with you?
    Invalid Input
  10. What emotional and/or behavioral changes have you been experiencing since the death?
    Invalid Input
  11. Did the child witness the death?
    Invalid Input
  12. Did the child live with the person who died?
    Invalid Input
  13. Please describe their relationship.
    Invalid Input
  14. Any specific concern or other pertinent information (inappropriate or aggressive behavior incidents, remarriage, etc)?
    Invalid Input
  15. is the child having any specific difficulty in school or in relationships with others?
    Invalid Input
  16. If yes, please explain:
    Invalid Input
  17.  
  1. List any health problems, dietary needs or limitations while at camp:
    Invalid Input
  2. List any medications
    Invalid Input
  3. List any allergies
    Invalid Input
  4. What expectations do you have for Camp Samantha?
    Invalid Input
  5. What are the camper's hobbies, interests, or special talents?
    Invalid Input
  6. What are your hobbies, interests, or special talents?
    Invalid Input
  7. Has the child been in any support groups or sought counseling?
    Invalid Input
  8. If yes, please explain the type (such as art, music, etc)
    Invalid Input
  9. Please describe your child
    Invalid Input
  10. Please describe yourself
    Invalid Input
  11.  
  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
    Invalid Input
  3. Please indicate race/ethnic origin







    Invalid Input
  4.  
  1. Camper's T-shirt size






    Invalid Input
  2. Desired name for camp name tag
    Invalid Input
  3.  
  1. Parent or Guardian Name
    Invalid Input
  2. Occupation
    Invalid Input
  3. Relationship to camper (of the person who completed this form)
    Invalid Input
  4. Emergency Contact Information
    Please provide the name and contact information of the person to contact in case of an emergency
  5. Emergency Contact Name:
    Invalid Input
  6. Relationship to you
    Invalid Input
  7. Address
    Invalid Input
  8. City
    Invalid Input
  9. State
    Invalid Input
  10. Zip
    Invalid Input
  11. Daytime Phone
    Invalid Input
  12. Evening Phone
    Invalid Input
  13. Cell or Other Phone
    Invalid Input
  14. Email
    Invalid Input
  15.  
  1. I give my permission to (check all that apply):(*)



    Invalid Input
  2. I give my child permission to (check all that apply):(*)





    Invalid Input
  3. Does the child know how to swim?
    Invalid Input
  4. Does the child need flotation devices?
    Invalid Input
  5. 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.
  6. Type your full name in the box below to acknowledge agreement with above statement(*)
    Invalid Input
  7. Captcha - help us combat spam(*)
    Captcha - help us combat spam
      Refresh / Get New CaptchaInvalid Input