KIDSCENE Bereavement Camp Application

Child's Name:*
Birthdate:*
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Sex:
Nickname, if applicable:
School currently attending and grade:*
School:
Grade:
Address:*
Phone Number(s):*
Home:
Cell:
Diet Restrictions
Allergies:
Parent/Legal Guardian Name(s) :*
Parent/Legal Guardian Address:*
Parent/Legal Guardian Phone Numbers:
Home:
Cell:
Work:
Parent/Legal Guardian Email:
Bereavement History
Who was the person who died? (Full name and relationship to child.)
Cause of death:
Date of death:
Age of child at the time of the death:
Age of the person who died:
Where did the person die? Home? Hospital? Other?
Was the child present at the time of death? Explain circumstances:
Did the child attend funeral/memorial service? (Yes or No)
Have there been multiple deaths of loved ones experienced by this child? If yes, please explain the nature of the death and relationship to the child of person who died.
Any other changes/stresses in this child's life? (Divorce, illness, relocation?)
Has this child received any professional support? (psychologist, psychiatrist, pastoral counselor, school counselor) Yes or No? If yes, how long was professional support provided?
Is there anything else you would like us to know about your child?
Please identify child's present behaviors at home: