Registration: Camp Samantha for Kids – Stepping Stones of Hope

Call Us: (602) 264-7520
Email : info@steppingstonesofhope.org

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Camp Samantha for Kids Registration

If you are registering multiple campers, you will need to complete one form for each camper.

* required field

Camper Details

Camper's First Name *

Camper's Last Name *

Camper's Birth date *

Camper's Age *

Street Address *

City *

State *

Zip *

Contact Information

Your name (if different from camper)

What is your relationship to the camper?

Daytime Phone

Evening Phone

Cell/Other Phone

Email Address *

Details

How did you hear about this camp?

List the names and ages of any living siblings related to the camper.

What is the name of the person who has died?

How old was the deceased when they died?

What is the relationship of the deceased to the camper?

When did the death occur?

What was the cause of death? Please include any important details such as who was with the person when they died.

Did the child witness the death?

Yes

Did the child live with the deceased?

Yes

Describe the relationship the child had with the deceased.

Are there any specific concerns or other pertinent information (inappropriate or aggressive behavior incidents, remarriage, etc)

Is the child having any specific difficult in school or in relationships with others? If yes, please briefly describe them.

Does they child have any health issues, dietary needs, or limitations while at camp? If so, please describe.

Does the child require any medication while at camp? If yes, please list them.

Does the child have any known allergies? If yes, please list them.

What are you expectations for this camp?

What are the camper's hobbies, interests, or special talents?

Has the camper ever attended any support groups or sought counseling? If yes, please list the type of support group.

Tell us a little more about the child. Briefly describe them.

Demographics

This information is optional. The information gathered from these two questions on gender and race/ethnicity are used for statistical purposes only. This provides our organization with accurate statistics required for grant applications and ensures a diverse population is served.

Camper's gender

Female

Male

Non-binary

Prefer not to answer

Race/ethnicity of camper

Hispanic or Latino

White

Black or African American

Asian

American Indian or Alaskan Native

Native Hawaiian or Pacific Islander

Emergency Contact Information

Provide an additional emergency contact in case we are unable to reach you.

Emergency Contact Full Name

Day Phone

Evening Phone

Mobile Phone

Camp Name Tag & T-shirt

Desired name on camp name tag

Camper's T-shirt size

Youth Medium (10-12)

Youth Large (14-16)

Adult Small (34-36)

Adult Medium (38-40)

Adult Large (42-44)

Adult X-Large (46)

Consent

I give my child permission to: *

Attend Camp Samantha

Have photos taken while at camp

Receive emergency medical care

Receive regular medications administered by a volunteer nurse

I hereby release Stepping Stones of Hope in the case of injury. *

Yes

Stepping Stones of Hope/Camp Samantha reserves the right to use photos and video for promotional purposes.

By typing your full name in the box below, you agree to the conditions outlined in this form. *