Camper Application – Step 4 C1

Camp Dates for Child

You can select to apply for programs and camp dates for each child depending on their age.

Are you applying for

Camp Magic (next available)
Family Day Camp
Healthy Grieving virtual camp
Let's talk Suicide virtual camp
Graduation Camp

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Camp Magic Dates applying for*

Family Day Camp Dates applying for*

Healthy Grieving Virtual Camp

Let's Talk Suicide Virtual Program

Camper Information

Name*

First Name Last Name

Preferred Name

Gender*

D.O.B*

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Age*

Childs T-Shirt Size*

School*

School Grade*

Main Language Spoken At Home*

Face to Face camp questions

Does this child have any allergies?*

Please list child's allergies

Does this child have any dietary requirements?*

Please list child's dietary requirements

Camp Magic Related Questions

Does this child have any sleeping problems: i.e. Sleepwalking, Bedwetting, Nightmares, etc..*

Please specify what and best control measure

Does this child have any medical, disability or learning difficulties (Check all that apply)*

Please provide further information regarding any medical, disability or learning difficulties*

Is the child known to any child protection agencies*

Please list with whom they are registered with, along with a brief description

What do you want this child to learn from camp*

What type of mentor will best match this child*

Interests

What are this child's interest/hobbies*

Give a brief description of this child's personality*

Bereavement details

Deceased relationship to camper*

Other Relation

Age of your child at the time of death*

Did the child witness the death?*

Did the child attend the funeral/memorial service?*

What were your child’s reactions to/comments about the service?

Describe in detail the child’s relationship with the deceased and how his or her life has been affected by the death*

Counselling and Support Groups

Has the child been in any support groups or sought counselling?*

Has the child been in any support groups or sought counselling? (yes, please elaborate)

Has the child ever received mental health counselling?*

Has the child ever received mental health counselling? (If yes, please elaborate)

Name of Mental Health Professional

Contact Number of Mental Health Professional

Mental Health Professional's Contact Email Address*

Consent to contact child’s mental health professional?*

From time to time our Head Psychologist may need to consult with your child's Psychologist / Counsellor

Child's Experience and Behaviours

Has the child exhibited any of the following behaviours since the death? (Check all that apply)*

If yes to any of the above, please elaborate

Please explain how the child expresses grief and what triggers emotions such as: Anger, Sadness, Depression, etc.*

Has the child experienced any of the following? (Check all that apply)*

If yes to any of the above, please elaborate

Has the child said or done anything recently that has concerned you?*

What behaviour has you concerned?

How does your child connect with and relate to peers?*

Have you and the child talked about him/her coming to Camp?*

Is there anything else we should know about the child?*

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