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Camp Courage Bereavement Camp

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Camp Courage Bereavement Camp

We are so pleased that you are considering Camp Courage as a way of supporting your child in dealing with the death of a significant person in their lives. Camp Courage offers children a safe place to share their feelings of grief and to learn coping skills to help them on their grief journey. Through a variety of guided activities based on the age of the child, they learn to express their grief and hopefully some coping strategies.

Camp Courage is a bereavement outreach of Central Missouri Hospice and is made possible through Hospice Promise Foundation grants, fund-raising activities and the generosity of volunteers and donors in our community. Camp Courage is free to all children and families who attend.

All of the information that we request is important to our staff as we are entrusted with your child. If a question has * next to it then it is required. We will contact you after we receive your application to set up an appointment for a phone interview to learn more about your child and their grief. If you have any questions, please contact us at 573-681-3750 or email Amy Schnoebelen

Step 1 of 7

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First Camper Information

My family was referred to Camp Courage by:
Name*
First Last
Organization
Camper's full name*
First Middle Last
Name to appear on nametag*
Date of birth*
MM slash DD slash YYYY
Age*
Gender*
Camper address*
Street Address Address Line 2 City State ZIP Code
Name of school*
Grade*
Ethnicity*
Religious affiliation (if any)
Relationship to the deceased
T-shirt size (Youth)
- Small
- Medium
- Large
- X-Large
T-shirt size (Adult)
- Small
- Medium
- Large
- X-Large
- 2X-Large
- 3X-Large
Name of siblings, age and gender
Camper Health Information
Food Allergies (Please provide severity, reactions, and any other information)
Drug Allergies (Please provide severity, reactions, and any other information)
Animal allergies
Dietary restrictions
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:
Do you need to register a second camper?*
- Yes
- No

Second Camper Information
Camper's full name*
First Middle Last
Name to appear on nametag*
Date of birth*
MM slash DD slash YYYY
Age*
Gender*
Camper address*
Street Address Address Line 2 City State ZIP Code
Name of school*
Grade*
Religious affiliation (if any)
Ethnicity*
Relationship to the deceased
T-shirt size (Youth)
- Small
- Medium
- Large
- X-Large
T-shirt size (Adult)
- Small
- Medium
- Large
- X-Large
- 2X-Large
- 3X-Large
Name of siblings, age and gender
Camper Health Information
Food Allergies (Please provide severity, reactions, and any other information)
Drug Allergies (Please provide severity, reactions, and any other information)
Animal allergies
Dietary restrictions
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:
Do you need to register a third camper?*
- Yes
- No

Third Camper Information
Camper's full name*
First Middle Last
Name to appear on nametag*
Date of birth*
MM slash DD slash YYYY
Age*
Gender*
Camper address*
Street Address Address Line 2 City State ZIP Code
Name of school*
Grade*
Religious affiliation (if any)
Ethnicity*
Relationship to the deceased
T-shirt size (Youth)
- Small
- Medium
- Large
- X-Large
T-shirt size (Adult)
- Small
- Medium
- Large
- X-Large
- 2X-Large
- 3X-Large
Name of siblings, age and gender
Camper Health Information
Food Allergies (Please provide severity, reactions, and any other information)
Drug Allergies (Please provide severity, reactions, and any other information)
Animal allergies
Dietary restrictions
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:

Parent/Guardian’s Information
Name*
First Last
Name to appear on nametag*
If guardian, relationship to camper
Address if different from camper
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone
Email*
Enter Email Confirm Email
Ethnicity*
Religious affiliation (if any)
Gender*
Relationship to deceased
T-shirt size (Youth)
- Small
- Medium
- Large
- X-Large
T-shirt size (Adult)
- Small
- Medium
- Large
- X-Large
- 2X-Large
- 3X-Large
Food Allergies (Please provide severity, reactions, and any other information)
Drug Allergies (Please provide severity, reactions, and any other information)
Animal allergies
Dietary restrictions
How do you feel you are coping with the loss of your loved?
What is the most concerning issue or challenge for your family?
Do you want to register a second adult?*
- Yes
- No

Second Adult’s Information
Name*
First Last
Name to appear on nametag*
If guardian, relationship to camper
Address if different from camper
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone
Email*
Enter Email Confirm Email
Ethnicity*
Religious affiliation (if any)
Gender*
Relationship to deceased
T-shirt size (Youth)
- Small
- Medium
- Large
- X-Large
T-shirt size (Adult)
- Small
- Medium
- Large
- X-Large
- 2X-Large
- 3X-Large
Food Allergies (Please provide severity, reactions, and any other information)
Drug Allergies (Please provide severity, reactions, and any other information)
Animal allergies
Dietary restrictions
How do you feel you are coping with the loss of your loved?
What is the most concerning issue or challenge for your family?

Emergency Contact (other than parent/guardian)
Name*
First Last
Relationship to the camper*
Home Phone*
Cell Phone
Name
First Last
Relationship to the camper
Home Phone
Cell Phone

Bereavement History
Camper’s special person who died*
Relationship*
Age of person
Date the death occurred*
MM slash DD slash YYYY
Cause of death
Age of camper(s) at the time of the death
Briefly describe the relationship that existed between the camper and the deceased.
Did the camper reside with the person who died?
- Yes
- No
Does the camper know the facts about the cause of death?
- Yes
- No
Did the camper attend the funeral or memorial service? If so, please describe their reaction.
Has your camper(s) experienced other deaths? If yes, please explain:
Have there been any other changes or stressful situations in your child’s life? (Separation, divorce, remarriage, relocation, illness, etc.)? Please describe:
Please explain how your child(ren) indicates he/she is still grieving.
What are your hopes/expectations for your family in attending Camp Courage?
Is there any other pertinent information that you think we should know?
e-Signature of Parent/Guardian*
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