Camp Compass Registration ⋆ Four Seasons

Camper Information

Name *

First

Last

Preferred Name *

Gender *

Male
Female

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth (MM/DD/YYYY) *

Age *

School Name *

Grade (2023-2024 School Year) *

T-Shirt Size *

Parent/Legal Guardian #1

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Contact Number *

Email *

Parent/Legal Guardian #2

Would you like to list a second Parent/Legal Guardian? *

Yes
No

Additional Emergency Contact

In the event that one of the two Parents/Legal Guardians are unavailable.

Name *

First

Last

Relationship to Child *

Primary Contact Number *

Information about the Death/Loss Child is Experiencing

Relationship of Child to the Deceased/Ill Person *

Date of Death/Onset of Illness (MM/YYYY) *

Age of Deceased/Ill Loved One *

Was/Is this person a patient at Four Seasons? *

Yes
No

Cause of Death *

Is this your child's first experience with death/loss? *

Yes
No

Did your child attend a memorial service for the deceased? *

Yes
No
N/A: Has not passed yet or no memorial held

Has your child received any professional mental health support since the death/onset of illness? *

Yes
No

How would you describe the quality, closeness, etc. of the relationship between the child and their deceased/ill loved one? *

Has the child experienced other impactful deaths? *

Yes
No

Are there any other changes or challenges impacting the child (divorce, incarceration, financial hardship, etc.)? *

Yes
No

Which of the following have been helpful to your child during their grief journey? Check all that apply. *

Has the child ever experienced abuse or neglect of any kind? *

Yes
No

Is there anything else you would like us to know about the child? *

If not, please put "N/A" or "No."

I attest that this grief history is accurate to the best of my knowledge. *

I Agree

The information I have provided is confidential and will only be used by the staff and volunteers present at the camp for the purpose of supporting my child in the best way possible. *

I Understand

Health History/Medical Information

The purpose of this information is to ensure that should medical treatment be necessary, medical personnel have details of any medical problem which may interfere with or affect treatment.

Child's Height *

Child's Weight *

Please explain any “checked” answers from the previous question. Indicate any information important to know in relation to any of your child’s health history / health conditions. *

If you selected "None," please put N/A in this box.

I understand that I will be notified in the case of a medical emergency involving my child. If I cannot be reached, I authorize the calling of a doctor and providing of necessary medical services in the event my child is injured or becomes ill. *

I understand

I understand that Four Seasons, its’ owners and its’ employees and volunteers will not be responsible for any medical expenses that may be incurred, but that such expenses will be my responsibility as the parent / legal guardian. *

I understand

Primary Care Provider (PCP) Name *

PCP Phone Number *

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason (including regularly taken OTC medications)? *

Yes
No

Does your child have food, medication, or environmental allergies? *

Yes
No

Are there any restrictions or limitations for your child on camp activities? *

If not, please put "N/A" or "No."

Is there any additional medical information that we need to be aware of for your child? *

If not, please put "N/A" or "No."

I understand that if an emergency occurs during the camp day, or if the camper becomes ill, camp staff will contact 911 if the on-site nurse deems it necessary. *

I Understand

I give permission to the Four Seasons/Camp Compass nurse to administer prescriptions, over the counter medications brought from home, first aid and/or access to medical treatment if needed for my child. *

I agree

Authorization for Medication Administration

Does your child have any medication that needs to be administered during camp? *

Yes
No

Acknowledgment of Risk and Assumption of Liability

I understand that during my participation in all activities at Hickory Nut Gap Farm during Camp Compass 2023 on August 11, 2023, we will be exposed to risks. I also understand that although Hickory Nut Gap Farm has taken precautions to provide proper equipment and specific instructions for the activities used, it is impossible to guarantee absolute safety. I understand that we share the responsibility for safety at the camp and in the activities and we assume that responsibility. I have accepted responsibility to verify with my physician that we have no physical or psychological problems that would prohibit our participation in the program. I agree to comply with the instructions, directions, and rules of Hickory Nut Gap Farm and staff members during the program. *

I understand

Permission to Pick Up

Does anyone besides a parent/legal guardian have permission to pick up your child from camp? *

Yes
No

Informed Consent and Indemnification Agreement

I hereby give permission for my child to attend Camp Compass on Friday August 11, 2023. I understand that the camp’s goal is to help facilitate the bereavement process of my child and provide support for him/her in expressing feelings of grief. *

I Agree

2. In due consideration of the above-named child being granted permission by Four Seasons to attend Camp Compass: WE/I, FOR OURSELVES/MYSELF AND ON BEHALF OF OUR/MY CHILD, RELEASE AND DISCHARGE FOUR SEASONS, ITS OFFICERS, DIRECTORS, ADMINISTRATORS, VOLUNTEERS, EMPLOYEES, AGENTS, SUCCESSORS, AND ASSIGNS, AND ALL OTHER PERSONS WHO ARE ASSOCIATED WITH FOUR SEASONS WHO MIGHT BE CLAIMED TO BE LIABLE FROM ANY AND ALL CLAIMS, DEMANDS, ACTIONS, JUDGMENTS, CAUSES OF ACTION OR SUITS OF ANY KIND OR NATURE WHATSOEVER, EITHER IN LAW OR EQUITY, WHICH WE/I OR OUR/MY CHILD EVER HAD OR NOW HAS OR MAY HAVE AGAINST FOUR SEASONS AND FROM ANY LIABILITY ON ITS PART ARISING FROM OR BY REASON OF ANY MATTERS AND THINGS WHATSOEVER INCLUDING BUT NOT LIMITED TO BODILY INJURY OR PERSONAL INJURIES, PHYSICAL OR EMOTIONAL, KNOWN OR UNKNOWN, SUSTAINED BY OUR/MY CHILD AND/OR THE DAMAGE OR INJURY TO PROPERTY, REAL OR PERSONAL OR OTHERWISE, SUSTAINED BY OUR/MY CHILD’S PROPERTY FROM THE COMMENCEMENT OF THE CHILD BEING ACCEPTED AND GRANTED PERMISSION TO ATTEND Camp Compass BY FOUR SEASONS THROUGHOUT HIS/HER ATTENDANCE AT Camp Compass UNTIL SAID CHILD IS RETURNED INTO OUR/MY CARE, HOWEVER SAID INJURY OR DAMAGE MAY OCCUR, WHETHER THE CAUSE IS BY NEGLIGENCE OF THE CHILD OR BY FOUR SEASONS OR THROUGH ANY OTHER FAULT. *

I Agree

3. In due consideration of the above-named child being granted permission by Four Seasons to attend Camp Compass: WE/I AGREE, JOINTLY AND SEVERALLY, TO INDEMNIFY AND HOLD FOUR SEASONS HARMLESS AGAINST ANY LIABILITY ON ITS PART FOR ANY CLAIMS, DEMANDS, ACTIONS, JUDGMENTS, CAUSES OF ACTIONS OR SUITS OF ANY KIND OR NATURE WHATSOEVER, EITHER IN LAW OR EQUITY, ARISING OUT OF ANY MATTERS AND THINGS WHATSOEVER INCLUDING BUT NOT LIMITED TO BODILY INJURY OR PERSONAL INJURIES, PHYSICAL OR EMOTIONAL, KNOWN OR UNKNOWN, SUSTAINED BY OUR/MY CHILD AND/OR THE DAMAGE OR INJURY TO PROPERTY, REAL OR PERSONAL OR OTHERWISE, SUSTAINED BY OUR/MY CHILD’S PROPERTY FROM THE COMMENCEMENT OF THE CHILD BEING ACCEPTED AND GRANTED PERMISSION TO ATTEND Camp Compass BY FOUR SEASONS THROUGHOUT HIS/HER ATTENDANCE AT Camp Compass UNTIL SAID CHILD IS RETURNED INTO OUR/MY CARE, HOWEVER SAID INJURY OR DAMAGE MAY OCCUR, WETHER THE CAUSE IS BY NEGLIGENCE OF THE CHILD OR BY FOUR SEASONS OR THROUGH ANY OTHER FAULT. *

I Agree

4. The purpose of this Agreement is to obtain from the child’s parent(s)/guardian(s) a release, discharge and indemnification for all matters delineated above. *

I Agree

5. This Agreement shall be binding on and shall insure to the benefit of the parties and their respective legal representatives, employees, agents, successors, heirs and assigns. *