Grief Camp Registration

To register a camper for Caterpillar’s Quest or SOAR grief camp, please complete the form below.

If you are having trouble accessing this form, please contact Shelley Kirby, Kids Path Support Specialist, at [email protected] or by calling 336-672-9300.

Caterpillar’s Quest and SOAR are provided by Hospice of the Piedmont and Hospice of Randolph’s Kids Path program.

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Camper Information
(please complete a separate registration form for each camp participant)
Camper's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Camper's age:*
Please enter a number from 1 to 25.
Name of camper's school:*
School grade for current year:*
This camper will attend:*
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Parent/Guardian Contact Information
Parent/Guardian's Name*
First Last
Phone Number*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How did you hear about camp?*
What are your expectations of camp?*
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Tell Us About the Loss
Please share the name and age of the deceased as well as the camper's relationship to the individual.*
Cause of death:*
When did the death take place?*
Was the camper present at the death?*
Did the camper live with the person who died?*
Have there been other changes/stresses in camper's life? (i.e. divorce, remarriage, relocation, illness)*
Is the camper having any specific difficulty in school or in relationships with others? (i.e. inappropriate behavior, aggression, withdrawal, etc.)*
In addition to the loss shared above, what other deaths/losses has the camper experienced? When did these take place?*
Has the camper participated in grief support or counseling? If so, please explain.*
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Participant Medical History
A nurse will be on-site during Caterpillar’s Quest and SOAR to administer medication and attend to any medical needs. Please provide the following information regarding your child’s Health History and Medications.
Does this camper have health insurance?*
Insurance Company*
Policy Number*
Group Number*
Insurance Effective Date*
MM slash DD slash YYYY
Preferred Hospital*
Physician's Name*
Physician's Phone Number*
If parent/guardian is not available in an emergency, name an emergency contact here.*
Phone Number (for emergency contact)*
Does the camper have any health conditions or allergies?*
Health Conditions or Allergies (select all that apply):*
- Frequent Ear Infections
- Heart Defect/Disease
- Asthma
- Diabetes
- Behavior Problems
- Epilepsy
- Hay Fever/Sinus
- Ivy Poisoning, etc.
- Insect Stings
- Food
- Other
Please explain any health conditions or allergies marked above.*
Has the camper had any of the following? (select all that apply)*
- Chicken Pox
- Measles
- German Measles
- Mumps
- Hepatitis
- None of these conditions
Please share the approximate date of any condition marked above.*
Does the camper have any physical limitations?*
Please explain the limitations.*
Has the camper had any surgeries or serious injuries?*
Please list and include the date of any surgeries or serious injuries.*
Does the camper have any chronic or recurring illnesses? (physical or emotional)*
Please explain the illness.*
Does the camper have a prescribed meal plan, dietary restrictions, or food allergies?*
Please explain.*
Does the camper take any medications?*
For each medication, please list the medication name, dose, frequency and how it is administered (orally, injection, etc.).*
PLEASE NOTE: All prescription medications must be brought to this event in their original container from the pharmacy, properly labeled with current dosage. Any changes from those on the container must be verified in writing by a physician. All medication must be turned over to the Health Care staff at camp registration the morning of the event.
May the Health Care staff administer Tylenol, if needed?*
If not, please list an approved alternative for Tylenol.*
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Participant Medical History Agreement
I hereby give my permission to the Caterpillar’s Quest and SOAR medical staff to administer regular medications, or any needed over-the-counter medication and provide on-site care for my child.
Parent/Guardian Signature*
By typing your name below, you are electronically signing the Participant Medical History Agreement and confirming the statement above.
First Last
Submission Date*
MM slash DD slash YYYY
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General Confidentiality Policy Agreement
Policy: Strict confidentiality of all Caterpillar’s Quest and SOAR event participant information is to be maintained at all times. Any information received that either directly or indirectly relates to Caterpillar’s Quest and SOAR participants is privileged and not subject to disclosure. Confidential participant information includes, but not limited to: the participant’s name, the scope and nature of concern/loss, nature of attendance, medical/mental health/substance abuse/developmental disability histories, any information that will be adverse to health/ safety/or reputation of the participant’s or his/her family or significant other. I have read, understand, and agree to abide by the Caterpillar’s Quest and SOAR confidentiality policy as stated above. I understand that all information obtained through interview(s) or event visit is considered confidential. I understand that all information that is part of the participant/family record is considered confidential. I agree to respect the principle of confidentiality. Unauthorized disclosure of the confidential information is a crime punishable by the court and/or civil penalties.
Parent/Guardian Signature*
By typing your name below, you are electronically signing the General Confidentiality Policy Agreement and confirming the statement above.
First Last
Submission Date*
MM slash DD slash YYYY
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Parent/Guardian Consent and Liability Release Agreement
The undersigned does hereby give permission for this child to attend and participate fully in the activities of Caterpillar’s Quest and SOAR, programs of Hospice of the Piedmont and Hospice of Randolph’s Kids Path Program. I authorize an adult, in whose care the minor has been entrusted, to consent to any X-Ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under general or special supervision and on the advice of any physician or dentist licensed under the provision of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agree(s) to pay all cost and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. The undersigned also gives permission for their child to ride in any vehicles designated by the adult in whose care the minor child has been entrusted while attending and participating in activities sponsored by Hospice of the Piedmont and Hospice of Randolph. In consideration for being accepted by Hospice of the Piedmont and Hospice of Randolph for participation in Caterpillar’s Quest and SOAR activities, I, being 21 years of age or older, do for myself and for and on behalf of my child- participating hereby release, forever discharge and agree to hold harmless Caterpillar’s Quest, SOAR, Kids Path, Hospice of the Piedmont, Hospice of Randolph and the directors there of from any liability, claims and demands for personal injury, sickness or death, as well as the damage, and expense of any nature whatsoever which may be incurred by the undersigned and the child-participant in the above described event. Furthermore I and on behalf of this child participant hereby assume all risk of personal injury, sickness, death, damage and expenses as a result of participating in recreation and activities involved therein. Further, authorization and permission is hereby given to said event to furnish any necessary transportation, food and lodging for this participant. The undersigned further hereby agree(s) to hold harmless and indemnify said event, its directors, employees and agents, for liability sustained by said event as the result of the neglect, willful or intentional acts of said participants, including expenses incurred attendant thereto. Further should it be necessary for the participant to return to home due to medical reasons, disciplinary action or otherwise, I will arrange for transportation home.
Parent/Guardian Signature*
By typing your name below, you are electronically signing the Parent/Guardian Consent and Liability Release Agreement and confirming the statement above.
First Last
Submission Date*
MM slash DD slash YYYY
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Media and Communications Permission Agreement
To communicate the Kids Path mission and message, I give permission for Hospice of the Piedmont and Hospice of Randolph to use photos, videotapes, quotations, stories, artwork, and other artistic expressions of the children and teens served through Caterpillar’s Quest and/or SOAR for purposes including but not limited to display boards, social media marketing, event promotions, brochures, newsletters, lectures and training sessions. The names of children and detailed information about children will not be spoken, shared, or printed. By signing this form, I give permission for Hospice of the Piedmont and Hospice of Randolph to utilize this content without my pre-approval, knowing that it will only be utilized to further the Kids Path mission.
Select one:*
- We give permission to the above uses of pictures, photos, artwork, quotations, stories, and videos.
- We give permissions with exceptions. (be sure to list exceptions below)
- We do NOT give permission to any of the above.
Please list exceptions:*
Parent/Guardian Signature*
By typing your name below, you are electronically signing the Media and Communications Permission Agreement and confirming the statement above.
First Last
Submission Date*
MM slash DD slash YYYY
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Name
This field is for validation purposes and should be left unchanged.

Grief Camp Registration

Camper Information

Parent/Guardian Contact Information

Tell Us About the Loss

Participant Medical History

Participant Medical History Agreement

General Confidentiality Policy Agreement

Parent/Guardian Consent and Liability Release Agreement

Media and Communications Permission Agreement