Camp Registration

Register for CAMP KANGAROO

HOW DID YOU HEAR ABOUT CAMP? *

NAME OF CHILD ATTENDING *

CHILD'S CURRENT AGE *

CHILD'S STREET ADDRESS *

CHILD'S CITY *

CHILD'S ZIP CODE *

YOUR NAME, PARENT OR GUARDIAN *

TELEPHONE *

EMAIL *

EMERGENCY CONTACT*

ALLERGIES *

MEDICAL CONDITIONS *

SPECIAL PERSON(S) WHO DIED: FULL NAME *

RELATIONSHIP *

AGE OF CAMPER AT THE TIME OF THE LOSS *

BRIEFLY DESCRIBE THE RELATIONSHIP BETWEEN THE CAMPER AND THE DECEASED.

DOES YOUR CHILD HAVE DIFFICULTY WITH ANY OF THE FOLLOWING AREAS? CHECK ALL THAT APPLY. NoneSleepingEatingSchoolRelationships

DOES YOUR CAMPER RECEIVE MEALS FROM SCHOOL FREE OF CHARGE?

---YesNo

ARE THERE ANY LANGUAGE, DISABILITY, OR OTHER NEEDS, FAMILY CUSTOMS, OR CULTURAL ASPECTS TO YOUR CHILD'S GRIEVING THAT WE SHOULD BE AWARE OF?

PLEASE PROVIDE US WITH ANY OTHER INFORMATION ABOUT YOUR CHILD THAT WILL BE HELPFUL IN PROVIDING A SUPPORTING CAMP EXPERIENCE.