Camp Dragonfly Pre-Bereavement Registration

Please fill out the below form for each child attending.

Please fill out the form below.

To be completed by the adult:

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Alt. Phone

Email(Required)

Re-enter Email(Required)

I am attending Camp Dragonfly with:(Required)

I am planning to go to Camp Dragonfly because: (Who in your life is terminally ill?):(Required)

Their Name(Required)

Name

Their relationship to you:(Required)

Date of death(Required)

Cause of death:

Media Release - I grant permission for photographs/videos, written evaluation comments, and or interviews with me (or my child/teen) to be used for educational purposes and/or to promote future events.(Required)

Yes

By checking this box, you are electronically signing and authorizing the use of the above materials to be used in the ways listed above.

Please list any other adults that will be attending

Camper Registration

Please complete with your child

What is your name?(Required)

First Last

How old are you?(Required)

What grade are you in?(Required)

I am planning to go to camp because: (Who in your life is very sick?)(Required)

Please mark all that apply:(Required)

I would like to meet other kids whose special person is sick.

I would like to learn ways to talk about my fears.

My parent(s)/guardian(s) really want me to attend

Other (please explain)

If you selected other, please explain

Is there anything else you would like us to know?

Camper Registration

To be filled out by camper's parent/legal guardian

Camper's legal name(Required)

First Last

Name that camper likes to be called:

Date of Birth(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent/Guardian name:(Required)

Relationship to camper:(Required)

Who is the person who is ill and what is their relationship to the camper?(Required)

Is the child aware that the diagnosis is terminal?

Has the child experienced other deaths?(Required)

Yes

If yes, please explain:

Comments

This field is for validation purposes and should be left unchanged.

Androscoggin Home Healthcare + Hospice

A nonprofit Medicare-certified agency based in Androscoggin County, Maine and covering Franklin, Cumberland, Kennebec, Oxford, Sagadahoc, and Somerset counties.

Camp Dragonfly Pre-Bereavement Registration