Good Grief Fun Camp Registration
Event Dates: July 20-24, 2020
Virtual Camp will be done via Putnam County Homecare & Hospice Facebook Page and Zoom.
Contact us at (419) 523-4449 or jmason@pchh.net.
Register by July 6th. Materials will be provided prior to camp for all those registered.
Email address *
Parent or Guardian Names *
Street Address *
City *
State *
Zip Code *
Telephone Home *
Telephone Cell *
Name of Child #1, Date of Birth, Sex *
Name of Child #2, Date of Birth, Sex
Name of Child #3, Date of Birth, Sex
Name of Child #4, Date of Birth, Sex
Name of Deceased Loved One, Relationship to Child, Date of Death *
Describe Circumstances Surrounding Death *
Concerns about Children's Adjustment / Recent Issues *
I give permission for my child/children to be photographed/videotaped for marketing. *
Required
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