Company
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Camper 1 Information Camper's Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Camper's age:* Name of camper's school:*
School grade for current year:* (select answer) Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade
This camper will attend:* (select answer) Caterpillar's Quest (Grades K - 6) SOAR (Grades 7 - 12)
Would you like to register another camper?* This field is hidden when viewing the form
Camper 2 Information Camper's Name (Camper 2)*
First
Last
Date of Birth (Camper 2)*
MM slash DD slash YYYY
Camper's age: (Camper 2)* Name of camper's school: (Camper 2)*
School grade for current year: (Camper 2)* (select answer) Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade
This camper will attend: (Camper 2)* (select answer) Caterpillar's Quest (Grades K - 6) SOAR (Grades 7 - 12)
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Parent/Guardian Contact Information Parent/Guardian's Name*
First
Last
Phone Number*
Email*
Address*
If parent/guardian is not available in an emergency, name an emergency contact here.*
Phone Number (for emergency contact)*
How did you hear about camp?*
What are your expectations of camp?*
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Tell Us About the Loss Please share the name and age of the deceased as well as the camper's relationship to the individual.*
Cause of death:*
When did the death take place?*
Was the camper present at the death?* (select answer) Yes No
Did the camper live with the person who died?* (select answer) Yes No
Have there been other changes/stresses in camper's life? (i.e. divorce, remarriage, relocation, illness)*
Is the camper having any specific difficulty in school or in relationships with others? (i.e. inappropriate behavior, aggression, withdrawal, etc.)*
In addition to the loss shared above, what other deaths/losses has the camper experienced? When did these take place?*
Has the camper participated in grief support or counseling? If so, please explain.*
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Camper 1 - Medical History Hospice of the Piedmont and Hospice of Randolph staff will be present at the bereavement camp to support your child’s safety and well-being. If a medical concern or emergency arises, staff will contact the child’s legal guardian and/or emergency medical personnel as needed. The medical information you provide is collected for emergency purposes only. It allows us to communicate clearly and effectively with you and with emergency personnel, if necessary.
Does this camper have health insurance?* (select answer) Yes No
Insurance Company*
Policy Number*
Group Number*
Insurance Effective Date*
MM slash DD slash YYYY
Preferred Hospital*
Physician's Name*
Physician's Phone Number*
Does the camper currently take any medications?* (select answer) Yes No
For each medication, please list the medication name, dose, frequency and how it is administered (orally, injection, etc.).*
Will the camper need to self-administer any medication while at camp?* (select answer) Yes No
PLEASE NOTE: All prescription medications must be brought to this event in their original container from the pharmacy, properly labeled with current dosage. Any changes from those on the container must be verified in writing by a physician. All medication must be turned over to staff at camp registration the morning of the event.
Please explain. (include medication name, dose, frequency, and any additional needed details)*
Does the camper have any allergies? (i.e. insect stings, food borne, medications, poison ivy, latex, etc.)* (select answer) Yes No
Please explain any allergies.*
Does the camper carry an EpiPen for any of these allergies that they are able to self-administer?* (select answer) Yes No
Is there anything else about the camper's medical history that is important for us to know?* (select answer) Yes No
Please explain.*
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Camper 2 - Medical History Hospice of the Piedmont and Hospice of Randolph staff will be present at the bereavement camp to support your child’s safety and well-being. If a medical concern or emergency arises, staff will contact the child’s legal guardian and/or emergency medical personnel as needed. The medical information you provide is collected for emergency purposes only. It allows us to communicate clearly and effectively with you and with emergency personnel, if necessary.
Does Camper 2 have the same health insurance as Camper 1?* (select answer) Yes No
Insurance Company for Camper 2*
Policy Number for Camper 2*
Group Number for Camper 2*
Insurance Effective Date for Camper 2*
MM slash DD slash YYYY
Preferred Hospital*
Physician's Name*
Physician's Phone Number*
Does Camper 2 currently take any medications?* (select answer) Yes No
For each medication, please list the medication name, dose, frequency and how it is administered (orally, injection, etc.).*
Will Camper 2 need to self-administer any medication while at camp?* (select answer) Yes No
PLEASE NOTE: All prescription medications must be brought to this event in their original container from the pharmacy, properly labeled with current dosage. Any changes from those on the container must be verified in writing by a physician. All medication must be turned over to staff at camp registration the morning of the event.
Please explain. (include medication name, dose, frequency, and any additional needed details)*
Does Camper 2 have any allergies? (i.e. insect stings, food borne, medications, poison ivy, latex, etc.)* (select answer) Yes No
Please explain any allergies.*
Does Camper 2 carry an EpiPen for any of these allergies that they are able to self-administer?* (select answer) Yes No
Is there anything else about Camper 2's medical history that is important for us to know?* (select answer) Yes No
Please explain.*
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Participant Medical History Agreement I hereby give my permission to the Caterpillar’s Quest and SOAR medical staff to administer regular medications, or any needed over-the-counter medication and provide on-site care for my child(ren).
Parent/Guardian Signature* By typing your name below, you are electronically signing the Participant Medical History Agreement and confirming the statement above.
First
Last
Submission Date*
MM slash DD slash YYYY
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General Confidentiality Policy Agreement Policy: Strict confidentiality of all Caterpillar’s Quest and SOAR event participant information is to be maintained at all times. Any information received that either directly or indirectly relates to Caterpillar’s Quest and SOAR participants is privileged and not subject to disclosure.
Confidential participant information includes, but not limited to: the participant’s name, the scope and nature of concern/loss, nature of attendance, medical/mental health/substance abuse/developmental disability histories,
any information that will be adverse to health/ safety/or reputation of the participant’s or his/her family or significant other. I have read, understand, and agree to abide by the Caterpillar’s Quest and SOAR confidentiality policy as stated above. I understand that all information obtained through interview(s) or event visit is considered confidential. I understand that all information that is part of the participant/family record is considered confidential. I agree to respect the principle of confidentiality. Unauthorized disclosure of the confidential information is a crime punishable by the court and/or civil penalties.
Parent/Guardian Signature* By typing your name below, you are electronically signing the General Confidentiality Policy Agreement and confirming the statement above.
First
Last
Submission Date*
MM slash DD slash YYYY
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Parent/Guardian Consent and Liability Release Agreement The undersigned does hereby give permission for this child(ren) to attend and participate fully in the activities of Caterpillar’s Quest and SOAR, programs of Hospice of the Piedmont and Hospice of Randolph’s Kids Path Program.
I authorize an adult, in whose care the minor has been entrusted, to consent to any X-Ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under general or special supervision and on the advice of any physician or dentist licensed under the provision of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agree(s) to pay all cost and expenses incurred in connection with such medical and dental services rendered to the aforementioned child(ren) pursuant to this authorization. The undersigned also gives permission for their child(ren) to ride in any vehicles designated by the adult in whose care the minor child has been entrusted while attending and participating in activities sponsored by Hospice of the Piedmont and Hospice of Randolph. In the event of an emergency, injury, inclement weather, or other extenuating circumstance, I give permission for this child(ren) to ride in a Hospice of the Piedmont and Hospice of Randolph staff member’s personal vehicle to get to appropriate shelter on campgrounds. In consideration for being accepted by Hospice of the Piedmont and Hospice of Randolph for participation in Caterpillar’s Quest and SOAR activities, I, being 21 years of age or older, do for myself and for and on behalf of my child(ren) - participating hereby release, forever discharge and agree to hold harmless Caterpillar’s Quest, SOAR, Kids Path, Hospice of the Piedmont, Hospice of Randolph and the directors there of from any liability, claims and demands for personal injury, sickness or death, as well as the damage, and expense of any nature whatsoever which may be incurred by the undersigned and the child participant(s) in the above described event.
Furthermore I and on behalf of this child participant(s) hereby assume all risk of personal injury, sickness, death, damage and expenses as a result of participating in recreation and activities involved therein. Further, authorization and permission is hereby given to said event to furnish any necessary transportation, food and lodging for this participant(s). The undersigned further hereby agree(s) to hold harmless and indemnify said event, its directors, employees and agents, for liability sustained by said event as the result of the neglect, willful or intentional acts of said participants, including expenses incurred attendant thereto. Further should it be necessary for the participant(s) to return to home due to medical reasons, disciplinary action or otherwise, I will arrange for transportation home.
Parent/Guardian Signature* By typing your name below, you are electronically signing the Parent/Guardian Consent and Liability Release Agreement and confirming the statement above.
First
Last
Submission Date*
MM slash DD slash YYYY
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Media and Communications Permission Agreement To communicate the Kids Path mission and message, I give permission for Hospice of the Piedmont and Hospice of Randolph to use photos, videotapes, quotations, stories, artwork, and other artistic expressions of the children and teens served through Caterpillar’s Quest and/or SOAR for purposes including but not limited to display boards, social media marketing, event promotions, brochures, newsletters, lectures and training sessions.
The names of children and detailed information about children will not be spoken, shared, or printed. By signing this form, I give permission for Hospice of the Piedmont and Hospice of Randolph to utilize this content without my pre-approval, knowing that it will only be utilized to further the Kids Path mission.
Select one:* Please list exceptions:*
Parent/Guardian Signature* By typing your name below, you are electronically signing the Media and Communications Permission Agreement and confirming the statement above.
First
Last
Submission Date*
MM slash DD slash YYYY
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Mount Shepherd Retreat Center (MSRC) - Release of Liability/Liability Waiver Form AGREEMENT TO PARTICIPATE: I understand the program goals and agree to participate in the programs and activities to the best of my ability. I agree and hereby state that I am aware and understand that all of the activities are strictly voluntary and it is my own choice to participate in each activity to whatever degree I deem appropriate and after due consideration of my own physical health, physical abilities and medical conditions. I have informed the Director of Mount Shepherd Retreat Center and/or the leader of the event of any medical conditions I may have. I further state that in choosing to participate I am not under the influence of any chemical substance including alcohol.
MEDICAL AND LIABILITY RELEASE: I willingly and knowingly assume for myself, my heirs, family members, executors, administrations and assigns all risk of physical injury and sickness and emotional upset which may occur during or after participating in any aspect of this event and hereby agree to hold Mount Shepherd Retreat Center its employees, instructors, facilitators, Board members and agents harmless for any liability arising out of my participation in the event. I hereby give permission to the Mount Shepherd Retreat Center parties and to contact emergency services for help, whether or not the MSRC parties have contacted my emergency contact, and give my permission to a licensed physician or other licensed medical provider to provide proper treatment, including but not limited to hospitalization, injection, anesthesia and/or surgery. I hereby RELEASE, WAIVE AND FOREVER DISCHARED MSRC from any and all claims, liabilities , causes of action, damages demands, judgments, executions, liens and costs whatsoever in law or equity, including, without limitation, liability for death or bodily injuries to any person or damage to any property resulting from any (1) claims made against medical providers of emergency services under this authorization, or (2) against the MSRC Parties for obtaining emergency medical series for me pursuant to this authorization and waiver.
Parent/Guardian Signature* By typing your name below, you are electronically signing the Mount Shepherd Retreat Center - Release of Liability/Liability Waiver Form and confirming the statement above.
First
Last
Submission Date*
MM slash DD slash YYYY
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Mount Shepherd Retreat Center (MSRC) - Media Release Do you grant the Mount Shepherd Retreat Center Parties all right, title and interest you may have in any and all photographs, motion pictures, video recordings, and any other recordings made during or about the event, and the MSRC parties shall have the right to use such recordings an unlimited number of times, in perpetuity by any and all means and media, now known or hereafter invented?
Select one:* Please list exceptions:*
Parent/Guardian Signature* By typing your name below, you are electronically signing the Mount Shepherd Retreat Center - Media Release Form and confirming the statement above.
First
Last
Submission Date*
MM slash DD slash YYYY
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