Dear Family Campers,
We look forward to having you and your child(ren) participate in Camp Phoenix,
Saturday, May 2 from 8:30am to 5:00 pm. This will be a fun and worthwhile
experience for your family.
For each family member attending, please complete the enclosed forms (Registration
Forms and Medical History) and return it by April 24, 2009. We must have all of these
forms completely filled out for your family to attend camp. A $10.00 deposit is required
to assure your reservation and should be sent in with these forms. The deposit will be
refunded to you when your family arrives at camp. A list of what your family should
and should not bring to camp is also enclosed. Please bring pictures of your loved one
to share during grief activities.
On Saturday, May 2, please plan to arrive at Karyae Park (which is where Camp
Phoenix is held) by 8:30 p.m. Directions are enclosed for your convenience. This is a
family event, so plan to attend with your child. The camp will end at 5:00 pm.
Please call the New Hope Counseling Center at (704) 861-8405 or email me if you have
any questions or need further information.
Sincerely,
Adrian Thornburg, MA, LPC
Camp Phoenix Coordinator
thornbua@gmh.org
CAMP PHOENIX CHILD REGISTRATION
Camper’s Name: _________________________________________________________
Date of Birth: ______________ Age: __________ T-shirt Size ___________________
School: ___________________________________ Grade: ______________________
Referred by: Self, TV, Hospice Flyer, School Counselor, other_____________________
PARENT INFORMATION
*The participation of at least one parent or legal guardian at camp is
required.
Parent/Guardian: _________________________________________________________
Address: ________________________________________________________________
Home Phone: ____________________
Cell:
____________________
Do both parents live in the home? Yes
Work Phone: ________________________
Email: ___________________________
No
If not, please provide the following contact information:
Parent/Guardian Name: ____________________________________________________
Mailing Address: _________________________________________________________
Home Phone: ____________________
Work Phone: ________________________
Cell:
____________________
Email:
________________________
Name & Relationship of deceased person to child _____________________________
Was deceased a Gaston Hospice patient? Yes No Give name: ___________________
Did camper live with the deceased? Yes No
Date of death: ___________________ Age at death: ____________________________
Type of Death: ( )Accident ( )Long term illness ( )Short term illness ( )Traumatic
(Murder/Suicide)
Was camper present at death: Yes No
Since the Death, what changes have you seen? (Check items)
() School Problems () Nightmares () Friends (fighting/withdrawal)
() Increase in fears () Expresses desire to die/kill self () Emotional struggles
(crying/confusion/guilt/bedwetting)
() Physical Symptoms (sleeping more/less, appetite, physical complaints) () none
() Other symptoms __________________________________________________
List other current stressors or significant losses for the child over the last 2 years
(ex: Divorce, loss of a pet, move, etc.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Has your child/teen been in any support groups or counseling? _________ If yes, please
explain:
________________________________________________________________________
Additional Information, Interests or Special Abilities:
_______________________________________________________________________
_______________________________________________________________________
I grant permission for photographs/slide show, written evaluation comments, or
interviews with my child to be used for educational purposes and/or to promote future
camps. I release Gaston Hospice and the Gaston County YMCA and its affiliates from
any claim or liability for that use.
Yes
No
________________________
Parent/Guardian Signature
________
Date
________________________
Parent/Guardian Signature
_________
Date
Children’s Medical Information
MEDICAL INFORMATION
Primary Care Phyisican: ________________________________________________
Phone number: _________________________________________________________
List any physical or mental concerns your child may have. ________________________
Are there any activities that should be restricted? ________________________________
________________________________________________________________________
List any allergies that we should know about (ex: Food, Hay Fever, Insect Stings,
Medications, Asthma, Latex, etc.):
Date of last immunizations: ______________________ Tetanus: __________________
AUTHORIZATION FOR TREATMENT:
I hereby give permission to camp personnel to release medical history information, to
contact the primary care physician, and/or to provide or arrange related transportation for
my child in case of emergency to the nearest medical facility. In the event I am unable to
give permission or be reached in an emergency, I hereby give permission to camp
personnel to secure and administer treatment, including hospitalization for my child. I
understand that no accident or medical insurance is provided and agree that I will be
financially responsible for medical treatment received.
Signature of Parent or Guardian__________________________________________
Date __________________________________________________________________
I give my permission for my child, __________________________, to participate in
the team building and ropes course activities as provided by the staff of the YMCA
of Gaston County while attending Camp Phoenix at Karyea Park YMCA Outdoor
Facility.
YES
NO
I understand that the New Hope Counseling Center for Grief and Loss, Gaston Hospice,
Inc., Caromont Health, Camp Phoenix, Gaston YMCA, camp staff/volunteers will not be
held liable in case of personal accident and/or injury, illness, or property loss or damage.
Parent/Guardian Signature _____________________________ Date ____________
Informed Consent for Camp Phoenix
Gaston Hospice
*The goal for children attending Camp Phoenix is to leave with a better understanding
of what grief is and how to use their personal coping skills.
*Camp Phoenix is a structured environment that will assist with grieving emotions that
present themselves in children when a close family member dies. Although there will be
fun, games, and music at the camp, there will also be counseling groups structured for
campers to explore their own personal emotions and the grieving process. Most people
chose counseling with hopes of feeling better. However, as with any powerful
intervention, there are both benefits and risks associated with counseling. Risks might
include experiencing uncomfortable feelings like sadness, anxiety, anger, guilt, or
frustration. It is not uncommon for children/adolescents/adults to report feeling worse
after the first few sessions. It is our goal to support the entire family as they sort through
these feelings and guide them toward more self-direction in their life (an identified
benefit of counseling).
*Client information is confidential in regards to other agencies or persons. However,
North Carolina state law requires exceptions to this rule in the case of: a) suspected child
abuse, b) suspected elder abuse, c) suspected domestic violence, d) stated intention to
injure another person, e) imminent danger of harming oneself, f) subpoena from a court
of law. In these situations, the appropriate agency or persons will be notified.
Symptoms to Look for After Camp
Sleep disturbances
Fatigue (related to grief work)
Headaches
Anger
Dreams
Stomachaches
Fear
Preoccupation
Withdrawal
Relief
Confusion
Anxiety
Sadness
Verbal attacks
Crying
Extreme Quietness
Nightmares
What to Do?
Continue with open communication with child.
Let the child know that you are prepared to talk with them when they are ready.
Don’t force the child to talk before he/she is ready.
Call the counselors at Gaston Hospice with any concerns. We are available to any child
or family who attends camp by calling 704-861-8405.
I have read the above and understand the goals, benefits, and risks of Camp
Phoenix.
______________________________
__________________________
Parent Signature
Date
______________________________
__________________________
Witness Signature
Date
Parent Copy
Informed Consent for Camp Phoenix
Gaston Hospice
*The goal for children attending Camp Phoenix is to leave with a better understanding
of what grief is and how to use their personal coping skills.
*Camp Phoenix is a structured environment that will assist with grieving emotions that
present themselves in children when a close family member dies. Although there will be
fun, games, and music at the camp, there will also be counseling groups structured for
campers to explore their own personal emotions and the grieving process. Most people
chose counseling with hopes of feeling better. However, as with any powerful
intervention, there are both benefits and risks associated with counseling. Risks might
include experiencing uncomfortable feelings like sadness, anxiety, anger, guilt, or
frustration. It is not uncommon for children/adolescents/adults to report feeling worse
after the first few sessions. It is our goal to support the entire family as they sort through
these feelings and guide them toward more self-direction in their life (an identified
benefit of counseling).
*Client information is confidential in regards to other agencies or persons. However,
North Carolina state law requires exceptions to this rule in the case of: a) suspected child
abuse, b) suspected elder abuse, c) suspected domestic violence, d) stated intention to
injure another person, e) imminent danger of harming oneself, f) subpoena from a court
of law. In these situations, the appropriate agency or persons will be notified.
Symptoms to Look for After Camp
Sleep disturbances
Fatigue (related to grief work)
Headaches
Anger
Dreams
Stomachaches
Fear
Preoccupation
Withdrawal
Relief
Confusion
Anxiety
Sadness
Verbal attacks
Crying
Extreme Quietness
Nightmares
What to Do?
Continue with open communication with child.
Let the child know that you are prepared to talk with them when they are ready.
Don’t force the child to talk before he/she is ready.
Call the counselors at Gaston Hospice with any concerns. We are available to any child
or family who attends camp by calling 704-861-8405.
Camp Phoenix Adult Registration
Name: _______________________________________________________________
T-shirt Size: _________________
Address: _______________________________City/State_____________Zip_______
Home Phone: __________________________Work Phone: _____________________
Email: _________________________________
Name and Relationship of deceased loved one:
__________________________________________________________________
If spouse, please circle:
Married
Separated
Divorced
Other significant losses in your life: _____________________________________
Changes I have seen in myself since the death:
1)
2)
3)
4)
Who is a part of your current support system? _____________________________
Are you currently involved in a grief support program? YES
NO
If yes, name of program and where it is held: ______________________________
What do you expect to get from this camp experience? ______________________
My greatest concern is _____________________________________________________
Permission
I grant permission for photographs/slide show written evaluation comments, or
interviews of me to be used for educational purposes and/or promote future camps.
Furthermore, I release the Gaston Hospice and the Gaston County YMCA from any claim
or liability for that use.
__________________________________
Signature
______________________________
Date
Adult Medical Information
Camp Phoenix
Name: ________________________________________________________________
First
Last
DOB: ________________
Age: _____________
List any physical concerns you may have. ________________________
Are there any activities that should be restricted? ________________________________
________________________________________________________________________
Any health problems, allergies, medications: ________________________________
_____________________________________________________________________
IN CASE OF EMERGENCY, THE CAMP SHOULD NOTIFY
Name: ________________________ Phone: _____________________________
Relationship: _________________________________________________
Secondary party to notify in case we cannot reach the person listed above:
Name: ________________________ Phone: _____________________________
Relationship: _________________________________________________
Primary Physician: __________________________ Phone: __________________
Name of Practice: ___________________________________________________
AUTHORIZATION FOR TREATMENT:
I hereby give permission to the camp medical personnel to release medical history
information, to contact the primary care physician, and/or to provide or arrange related
transportation in case of emergency to the nearest medical facility. I hereby give
permission to the camp medical personnel to secure and administer treatment, including
hospitalization for me. I understand that no accident or medical insurance is provided
and agree that I will be financially responsible for medical treatment received.
Signature __________________________________________ Date ____________
Camp Phoenix
Directions to Karyea Park
YMCA Outdoor Family Center
Gastonia, NC
Location: 4227 South Linwood Rd., Gastonia, NC 28052.
From Downtown Gastonia, take Franklin Blvd-US 74 to South
Linwood Road approximately 5 miles. The Outdoor Center will be
on your left before Camp Rotary Road.
You can MapQuest this at www.google.com using your home
address.
What to Bring to Camp
Tennis Shoes must be worn at camp at all times.
(You may want to bring an extra pair)
Dress for the weather/Rain Gear
Pictures of deceased love one for a project that can be cut, taped
or glued
Camera (optional)
Picnic Basket of food to feed
your family for Lunch
DO NOT BRING RADIOS, CD PLAYERS,
HAND HELD VIDEO GAMES, CELL PHONES, SANDALS
OR FLIPFLOPS