Camp Forget-Me-Not Registration Form

Complete and submit registration form by May 22. Enrollment is strictly limited to 60.
Information about Child
Child's First Name
Child's Last Name
Child's Street Address
City
Zip Code
County
Child's Ethnic Background











Child's Age
Child's Birthdate
Child's Gender



Child's T-Shirt Size (Adult Sizes Only)







Child's School System
Child's Current Grade
Name of Deceased
Relationship to Child
When did the death occur?
How did the death occur?
Did the child attend the funeral?



Has the child received any grief counseling? Please answer below. If yes, please describe in field below.
Previous grief support participation?



If Yes, please describe
Are there any other issues or details about the child’s relationship or grief process that would be helpful to Camp Forget-Me-Not staff? If so, please explain in the text field below.
Please provide additional details below.
With whom does the child reside?
Relationship to Child
Does the child have any special needs?
Person Completing this Registration Form
First Name
Last Name
Email address
Phone number
Your relationship to the child
Over the Counter Medications

The following over the counter medications are available at Camp Forget-Me-Not. Please indicate by answering YES or NO, whether you allow the administration of these medications to your child if needed.
Sunscreen



Insect Repellant



Mylanta Liquid



Tylenol Jr. Liquid



Tylenol Tabs (250mg)



Benadryl



Calamine Lotion



Triple Antibiotic Cream



Aloe Gel/Solarcaine



Do you wish to receive a phone call and be asked for your permission before administering any of the medications that you selected above? If so, please answer below
Please call for permission to administer



Emergency Contact
Name
Relationship
Cell Phone Number
Work Phone number
Other Phone number(s)
Child's Medical Information
History of Hospitalization



If yes, please describe
Other Medical History:



If yes, please describe
Height
Weight
Glasses/Contacts?



Hearing Aids?



Current Medications

If more than 3 medications, please contact Camp Forget-Me-Not to provide supplemental information.
Name of Medication 1
Reason for Medication 1
Dosage for Medication 1 and when
Name of Medication 2
Reason for Medication 2
Dosage for Medication 2 and when
Name of Medication 3
Reason for Medication 3
Dosage for Medication 3 and when
Immunization Dates:
MMR
Polio
Tetanus
Allergies?



If yes, be specific
Dietary Restrictions?



If Yes, please describe:
Activity Restrictions?



If yes, please describe
As parent/guardian, I authorize the Camp Forget-Me-Not nurse to administer the child’s medications per dosage or as may be needed per prescription instructions.

I understand that although I am submitting this registration via the Camp Forget-Me-Not web site,

I will be asked to confirm this registration by signing a hard copy of this registration on the evening of June 5 at Ele’s Place.

I understand that my child cannot attend Camp Forget-Me-Not without a signed confirmation of his/her registration and his/her medical history.
You may pay for the camp registration via PayPal by clicking the Paypal link on the registration page on the camp website. You may also pay in person the evening of June 4.
I understand that this registration is not complete until a signed copy of the Parental Permission/Bus Transportation Form is submitted or signed on the evening of June 4 during pre-registration at Ele’s Place.