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Registration
June 25-27, 2024
8:30 a.m. to 4 p.m. Daily
YMCA Camp Clay
9196 Liberty-Union Rd., Van Wert
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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 4 p.m. each day
(except the teen extended day on Wed). Camp is FREE and lunch and snacks are provided!
You MUST
REGISTER by Friday, June 7
Child's Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Sex
*
Male
Female
Required
Shirt Size
*
Youth S
Youth M
Youth L
Youth XL
Adult S
Adult M
Adult L
Adult XL
Adult 2XL
Adult 3XL
Parent/Guardian
*
Your answer
Address
*
Your answer
City/State/Zip
*
Your answer
Contact Phone
*
Your answer
Work phone
*
Your answer
Emergency Contact
*
Your answer
Address
*
Your answer
City/State/Zip
*
Your answer
Contact Phone
*
Your answer
Family Physician
*
Your answer
Phone
*
Your answer
Family Dentist
*
Your answer
Phone
*
Your answer
Allergies to foods, stings, medications, etc.
*
Yes
No
Required
If yes, list allergies
Your answer
Medical Issues?
*
Yes
No
Required
If yes, list condition(s)
Your answer
Will child require medication during camp?
*
Yes
No
Required
Medication #1
Your answer
Dose
Your answer
When to be taken
Your answer
Medication #2
Your answer
Dose
Your answer
When to be taken
Your answer
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
Your answer
Name of deceased loved one
*
Your answer
Date of Death
*
MM
/
DD
/
YYYY
Relationship to child
*
Your answer
Describe circumstances surrounding the death
*
Your answer
Concerns about children’s adjustment or issues noticed in the last year
*
Your answer
Who is allowed to pick up child at camp?
*
Your answer
Who is allowed to pick up child at camp?
Your answer
Parent/Guardian Signature
*
Your answer
Date
*
MM
/
DD
/
YYYY
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