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Camp Aloha Camper Application

Campers Information
Name*
Age*
Application Date*
Month
Day
Year
Race*
Gender - Child Identifies as:
- Male
- Female
- Non-Binary
Child's Preferred Pronouns:
- He/Him
- She/Her
- They/Them
Name the child/teen would like to be called
School attending/grade during camp (month of May)?*
Parent/Legal Guardian Name*
Guardian Relationship*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Cell Phone
Email*
Preferred Method of Pre-Camp Communication*
- Phone
- Email
- US Mail
Has the child/teen ever attended Camp Aloha?
- Yes
- No
Has the child/teen ever received Grief Counseling with Full Circle?*
- Yes
- No
How did you hear about Camp Aloha and Full Circle of Hospice Savannah?
Camper T-Shirt Size*
- Child - M
- Child - L
- Adult - S
- Adult - M
- Adult - L
- Adult - XL
Campers History
Has the child/teen ever spent the night away from home?*
- Yes
- No
If yes, describe any problems the child/teen may have experienced
Describe any sleep problems the child/teen may have (i.e. sleepwalking, bedwetting, nightmares)*
Please describe any other problems we should be aware of (i.e. eating disorder, getting along with friend/peers/family, school attendance, physical limitations)*
Please give name(s) and age(s) of other family or friends who will be at camp
Grief History
Regarding the person who died: Was that person under the care of Hospice Savannah, Inc?*
- Yes
- No
If no, was that person under the care of another hospice?
- Yes
- No
If in another hospice, what was the name of that Hospice program?
Please give the name of the person who died and the relationship to the child/teen.*
Where did the person die?*
- Home
- Hospital
- Hospice Inpatient Unit (HIPU)
- Other
Please Specify Where the Person Died
What was the date of death and cause of death?*
What was the age of your child/teen when the death occurred?*
Was the child/teen present at the time of the death?*
- Yes
- No
Please describe the child's/teen's reaction.*
Did the child/teen attend the funeral/memorial service?*
- Yes
- No
If yes, what was your child's/teen's reaction to/or comments about the service?*
Has your child/teen received any professional support (i.e., school counselor, peer support group, psychologist, psychiatrist, pastoral counselor)?*
- Yes
- No
If yes, is support currently being provided?
- Yes
- No
Please explain how your child/teen indicates he/she is still grieving.*
Has your child/teen experienced multiple deaths of loved ones?*
- Yes
- No
If yes, please describe the nature of the death and the child's relationship to the person(s) who died.
Health History
Please list any medical issues we need to be aware of, including serious allergies:*
Please list all medications the child/teen is taking, dosage, and times to be given:(Enter none if camper does not take anything.)*
ALL MEDICATIONS MUST BE IN ORIGINAL LABELED CONTAINERS.
Doctor's Name and Phone number*
Is the child/teen covered by health insurance?*
- Yes
- No
If yes, give name of insurance company
Policy Number
Policyholder's Name
Emergency Contact
In case of emergency, if we cannot reach you, please give name, relationship and phone number of whom we should contact.*
Transportation
TRANSPORTATION: I give permission for my child to be transported by bus to/from Full Circle Grief and Loss Center and New Ebenezer Retreat Center.*
- I fully agree with this statement.
- I do not agree with this statement.
Transportation Needed for my child to and from New Ebenezer Retreat:*
- None
- Round Trip
- Friday Only
- Sunday Only
Medical Release
I give my permission for the camp nurse to administer to my child his/her prescribed medication (if any) and/or over the counter medication as needed as well as administer first aid if necessary.*
- I fully agree with this statement.
- I do not agree with this statement.
Release of Liability
In consideration for attending the Camp Aloha for only a minimum registration fee of $25.00, I understand and agree that Hospice Savannah, Inc., its Board of Directors, Officers, Employees, Volunteers, and Camp Sponsors are released from any legal responsibility and/or liability for negligence arising out of any accidents or illnesses which may occur while my child/teen attends Camp Aloha.*
- I fully agree with this statement.
- I do not agree with this statement.
Mosquito Release
It is possible that there will be mosquitoes in the vicinity of New Ebenezer Retreat Center. Because of health considerations New Ebenezer Retreat Center does spray insecticide extensively. Camp Aloha will limit the campers' outdoor after-dusk acitvities to the bonfire/memorial service on Saturday night.*
- I fully agree with this statement.
- I do not agree with this statement.
Recording or Filming Release
I authorize Hospice Savannah, Inc., or local media and other professional assisting Hospice Savannah, to record images of my child/teen and conduct interviews with my child that may be seen and heard by the general public or used for performance improvement or education purposes. I understand these images may be used for educating the public about Hospice Savannah care or promoting programs and services offered by Hospice Savannah. I understand that I have the right to rescind this consent prior to the use of the recording or film.*
- I fully agree with this statement.
- I do not agree with this statement.
By typing my name and date into this form, I am attesting that all statements in this application are true with nothing knowingly misrepresented about my child/teen and confirms my permission with all consents.*
Registration Fee
There is a nominal non-refundable registration fee of $25 per child. If this is a financial hardship for you, please call Full Circle at (912) 303-9442. Payment can be made thru Venmo using the QR code, or by visiting https://hospicesavannah.org/give-2/donations/ , and noting Camp Aloha in the Designation field.