Camp Healing Hearts Family Application

Family Name, Address, Phone:  (* required)

* First Name
* Last Name
Street Address
Address (cont.)
* City
* State/Province
* Zip Code
Work Phone
* Home Phone	XXX-XXX-XXXX
FAX
* E-mail

Name (s) of the Deceased with Date of Death

Children Attending:

Name
Date of Birth	mm/dd/yyyy
Sex	Male Female

Children Attending

Name
Date of Birth	mm/dd/yyyy
Sex	Male Female

Children Attending:

Name
Date of Birth	mm/dd/yyyy
Sex	Male Female

Adults Attending:

Name
Date of Birth	mm/dd/yyyy
Sex	Male Female

Adults Attending:

Name
Date of Birth	mm/dd/yyyy
Sex	Male Female

Relationship of child(ren) to the deceased:

child
grandparent
sibling
other

Adult relationship to the deceased:

spouse
parent
sibling
child
other

Will you need childcare for children under 5 years old?

Yes No

Best time to call:

AM
PM

Emergency Contact:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail

How did you hear of Camp Healing Hearts?