Camp MAGIC Application

Thank you for choosing Camp MAGIC for your family! This one-day grief retreat for your entire family is available, free of charge, to children ages 6-12 who have experienced the death of a loved one. To register your family for camp, please complete this application.

Please note: If the date for submitting online applications has expired, the camp location will no longer appear as an option below. For more information, please call 888-488-7768.

CHOOSE A CAMP LOCATION

Available Dates

REFERRAL

My family was referred to Camp MAGIC by:

Name

Organization

FAMILY MEMBERS ATTENDING | Primary Adult Contact Information

First Name

Middle Initial

Last Name

Address

City

State

Zip Code

Phone Number

Email Address

Sex *

Male Female

Relationship to Camper

Name of Deceased

Relationship to Deceased

Ethnicity

Religious Affiliation

Name you want to appear on Name Tag

T-Shirt Size

Primary Adult Health Information:

List any food allergies

List any drug allergies

List any allergies to animals

List any dietary restrictions

List any other allergies not listed above

Please provide the names of any medications you may carry/need to counteract these reactions

Secondary Adult Contact Information

First Name

Middle Initial

Last Name

Address

City

State

Zip Code

Phone Number

Email Address

Sex

Male Female

Relationship to Camper

Name of Deceased

Relationship to Deceased

Ethnicity

Religious Affiliation

Name you want to appear on Name Tag

T-Shirt Size

Secondary Adult Health Information:

List any food allergies

List any drug allergies

List any allergies to animals

List any dietary restrictions

List any other allergies not listed above

Please provide the names of any medications you may carry/need to counteract these reactions

2nd Camper:

First Name

Last Name

Name to appear on Name Tag

Sex

Male Female

Age

T-Shirt Size

Relationship to deceased

2nd Camper's Health Information

List any food allergies (please provide severity, reactions, and any other information)

List any drug allergies (please provide severity, reactions, and any other information)

List any allergies to animals (please provide severity, reactions, and any other information)

List any dietary restrictions and their reactions

List any other allergies not listed above

Please give the names of any medicines you may carry/need to counteract these reactions

Can your child have sunscreen applied?

Yes No

Can your child have insect repellent applied?

Yes No

Please describe your child's personality/hobbies/talents or any other information you want us to know about your child?:

3rd Camper:

First Name

Last Name

Name to appear on Name Tag

Sex

Male Female

Age

T-Shirt Size

Relationship to deceased

3rd Camper's Health Information

List any food allergies (please provide severity, reactions, and any other information)

List any drug allergies (please provide severity, reactions, and any other information)

List any allergies to animals (please provide severity, reactions, and any other information)

List any dietary restrictions and their reactions

List any other allergies not listed above

Please give the names of any medicines you may carry/need to counteract these reactions

Can your child have sunscreen applied?

Yes No

Can your child have insect repellent applied?

Yes No

Please describe your child's personality/hobbies/talents or any other information you want us to know about your child?:

4th Camper:

First Name

Last Name

Name to appear on Name Tag

Sex

Male Female

Age

T-Shirt Size

Relationship to deceased

4th Camper's Health Information

List any food allergies (please provide severity, reactions, and any other information)

List any drug allergies (please provide severity, reactions, and any other information)

List any allergies to animals (please provide severity, reactions, and any other information)

List any dietary restrictions and their reactions

List any other allergies not listed above

Please give the names of any medicines you may carry/need to counteract these reactions

Can your child have sunscreen applied?

Yes No

Can your child have insect repellent applied?

Yes No

Please describe your child's personality/hobbies/talents or any other information you want us to know about your child?:

5th Camper:

First Name

Last Name

Name to appear on Name Tag

Sex

Male Female

Age

T-Shirt Size

Relationship to deceased

5th Camper's Health Information

List any food allergies (please provide severity, reactions, and any other information)

List any drug allergies (please provide severity, reactions, and any other information)

List any allergies to animals (please provide severity, reactions, and any other information)

List any dietary restrictions and their reactions

List any other allergies not listed above

Please give the names of any medicines you may carry/need to counteract these reactions

Can your child have sunscreen applied?

Yes No

Can your child have insect repellent applied?

Yes No

Please describe your child's personality/hobbies/talents or any other information you want us to know about your child?:

6th Camper:

First Name

Last Name

Name to appear on Name Tag

Sex

Male Female

Age

T-Shirt Size

Relationship to deceased

6th Camper's Health Information

List any food allergies (please provide severity, reactions, and any other information)

List any drug allergies (please provide severity, reactions, and any other information)

List any allergies to animals (please provide severity, reactions, and any other information)

List any dietary restrictions and their reactions

List any other allergies not listed above

Please give the names of any medicines you may carry/need to counteract these reactions

Can your child have sunscreen applied?

Yes No

Can your child have insect repellent applied?

Yes No

Please describe your child's personality/hobbies/talents or any other information you want us to know about your child?:

7th Camper:

First Name

Last Name

Name to appear on Name Tag

Sex

Male Female

Age

T-Shirt Size

Relationship to deceased

7th Camper's Health Information

List any food allergies (please provide severity, reactions, and any other information)

List any drug allergies (please provide severity, reactions, and any other information)

List any allergies to animals (please provide severity, reactions, and any other information)

List any dietary restrictions and their reactions

List any other allergies not listed above

Please give the names of any medicines you may carry/need to counteract these reactions

Can your child have sunscreen applied?

Yes No

Can your child have insect repellent applied?

Yes No

Please describe your child's personality/hobbies/talents or any other information you want us to know about your child?:

8th Camper:

First Name

Last Name

Name to appear on Name Tag

Sex

Male Female

Age

T-Shirt Size

Relationship to deceased

8th Camper's Health Information

List any food allergies (please provide severity, reactions, and any other information)

List any drug allergies (please provide severity, reactions, and any other information)

List any allergies to animals (please provide severity, reactions, and any other information)

List any dietary restrictions and their reactions

List any other allergies not listed above

Please give the names of any medicines you may carry/need to counteract these reactions

Can your child have sunscreen applied?

Yes No

Can your child have insect repellent applied?

Yes No

Please describe your child's personality/hobbies/talents or any other information you want us to know about your child?:

9th Camper:

First Name

Last Name

Name to appear on Name Tag

Sex

Male Female

Age

T-Shirt Size

Relationship to deceased

9th Camper's Health Information

List any food allergies (please provide severity, reactions, and any other information)

List any drug allergies (please provide severity, reactions, and any other information)

List any allergies to animals (please provide severity, reactions, and any other information)

List any dietary restrictions and their reactions

List any other allergies not listed above

Please give the names of any medicines you may carry/need to counteract these reactions

Can your child have sunscreen applied?

Yes No

Can your child have insect repellent applied?

Yes No

Please describe your child's personality/hobbies/talents or any other information you want us to know about your child?:

10th Camper:

First Name

Last Name

Name to appear on Name Tag

Sex

Male Female

Age

T-Shirt Size

Relationship to deceased

10th Camper's Health Information

List any food allergies (please provide severity, reactions, and any other information)

List any drug allergies (please provide severity, reactions, and any other information)

List any allergies to animals (please provide severity, reactions, and any other information)

List any dietary restrictions and their reactions

List any other allergies not listed above

Please give the names of any medicines you may carry/need to counteract these reactions

Can your child have sunscreen applied?

Yes No

Can your child have insect repellent applied?

Yes No

Please describe your child's personality/hobbies/talents or any other information you want us to know about your child?:

CONSENT

* I am the parent or legal guardian of the child(ren) listed within this application, and I hereby consent to their participation in Camp MAGIC. I hereby release, hold harmless, and forever discharge SSM Health, its affiliates, employees and representatives from any claim, demand, action or right of action, liability or cost any kind or nature rising from or by reason of such child's participation in Camp MAGIC, except to the extent the same is caused by the wrongful conduct of SSM Health.

PHOTOGRAPHY

A professional photographer will be on site to take pictures of special moments throughout the day. Pictures will only be used for promotional purposes (i.e. photo books to donors and/or advertising and flyers to promote the event). Is it okay for you and/or your child to be photographed?

Electronic Signature

* I certify that the information in this application is true and correct to the best of my knowledge. I understand that if I knowingly provide untrue information in this application, I will be ineligible for participation.

I understand that by entering an electronic signature and check the box, I am submitting a legal signature.

Camp MAGIC Application

CHOOSE A CAMP LOCATION

REFERRAL

FAMILY MEMBERS ATTENDING | Primary Adult Contact Information

Primary Adult Health Information:

Secondary Adult Contact Information

Secondary Adult Health Information:

FAMILY MEMBERS ATTENDING | Child Camper Information

1st Camper:

1st Camper's Health Information

2nd Camper:

2nd Camper's Health Information

3rd Camper:

3rd Camper's Health Information

4th Camper:

4th Camper's Health Information

5th Camper:

5th Camper's Health Information

6th Camper:

6th Camper's Health Information

7th Camper:

7th Camper's Health Information

8th Camper:

8th Camper's Health Information

9th Camper:

9th Camper's Health Information

10th Camper:

10th Camper's Health Information

CONSENT

PHOTOGRAPHY

Electronic Signature