Registration
July 23-25, 2024
8:30 a.m. to 3:00 p.m. Daily
Defiance Area YMCA
1599 Palmer Dr., Defiance
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Rays of Hope is a camp for children and youth ages 6-17 (grades K-12) who have recently experienced the loss of a loved one or friend. It helps kids understand that they are not alone and that having fun is part of healing.

Rays of Hope is led by CHP Hospice staff trained in children’s loss issues. Check in 8:30 a.m. and pick up 3 p.m. each day. Camp is FREE and lunch and snacks are provided! 
You MUST REGISTER by Friday, July 5
 Child's Name *
Date of Birth *
ДД
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ММ
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Sex *
Обавезно
Shirt Size *
Parent/Guardian *
Address *
City/State/Zip *
Contact Phone *
Work phone *
Emergency Contact *
Address *
City/State/Zip *
Contact Phone *
Family Physician *
Phone *
Family Dentist *
Phone *
Allergies to foods, stings, medications, etc. 
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Обавезно
If yes, list allergies
Medical Issues? *
Обавезно
If yes, list condition(s)
Will child require medication during camp? *
Обавезно
Medication #1
Dose
When to be taken
Medication #2
Dose
When to be taken
If medication is to be administered to a child, a medication order form must be completed by your physician.
Download form: https://comhealthpro.org/wp-content/uploads/2023/03/MD-Med-Form.pdf
List any dietary restrictions
Name of deceased loved one *
Date of Death *
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ММ
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Relationship to child *
Describe circumstances surrounding the death
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Concerns about children’s adjustment or issues noticed in the last year
 *
Who is allowed to pick up child at camp? *
Who is allowed to pick up child at camp?
Parent/Guardian Signature *
Date *
ДД
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ММ
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