2017 Camper Application Camp Erin Boston
There are two date options for Camp Erin Boston in 2017.
Campers can attend ONLY one session which you can select in the form below.


Camp Erin Boston Session ONE will be held Friday, June 9, 2017 through Sunday, June 11, 2017 at Camp Bauercrest in Amesbury, MA.

Camp Erin Boston Session TWO will be held Friday, August 18, 2017 through Sunday, August 20, 2017 at Camp Bauercrest in Amesbury, MA.

Camp Erin Boston is offered FREE OF CHARGE to all campers.

Who can attend Camp Erin?
-Any child or teen, ages 6-17 who has experienced the death of someone close to them in their lifetime.
-It does not matter how long ago the death occurred.
-It does not matter if the deceased was a participant of CareGroup Parmenter Home Care and Hospice.
-It does not matter where you live, as long as you are willing to travel to all events.
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SESSION ONE INFORMATION:

Camp Erin Boston Session ONE will be held Friday, June 9, 2017 through Sunday, June 11, 2017 at Camp Bauercrest in Amesbury, MA

What happens after I submit an application?
The Camp Director will contact you to schedule an interview.

Due to space limitations, we can only accept 50 campers each session. Preference is given to those who have never attended Camp Erin.

-Interviews will be conducted January-May, 2017. We will contact you to schedule an interview.

-Acceptance letters will be sent out by mid-April

_________________________________________________________________________________________________
SESSION TWO INFORMATION:

Camp Erin Boston Session TWO will be held Friday, August 18, 2017 through Sunday, August 20, 2017 at Camp Bauercrest in Amesbury, MA.

What happens after I submit an application?

APPLICATIONS FOR SESSION TWO (AUGUST) ARE DUE BY JUNE 1, 2017.

Due to space limitations, we can only accept 50 campers each session. Preference is given to those who have never attended Camp Erin.

-Interviews will be conducted January-June 2017. We will contact you to schedule an interview.

-Acceptance letters will be sent out by mid-June

-The Ice Cream Social is a REQUIRED event for all accepted campers.
It will be held on SUNDAY, JULY 16, 2017,
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CareGroup Parmenter Home Care & Hospice, Inc./Camp Erin Boston does not discriminate against any person on the basis of race, color, national origin, creed, religion, disability, marital status, sexual orientation, veteran status, or age in admission, treatment or participation in its programs, services, activities or employment.

Which Session is the Camper's first choice?
Please choose one option.
If the Camper's first choice session is full, is the other session a possibility?
If you check 'other' please explain.
Camper's First Name
Your answer
Camper's Last Name
Your answer
Camper's Date of Birth
MM
/
DD
/
YYYY
Camper's Age
If applying for June Session: Age camper will be by June 9, 2017 If applying for August Session: Age camper will be by August 18, 2017
Your answer
Camper's Sex
Parent or Legal Guardian's First Name
Your answer
Parent or Legal Guardian's Last Name(s)
Your answer
What is your relationship to the camper?
If you check 'other' please explain.
Required
Street Address
Your answer
City
Your answer
State
You may apply from any state as long as you are willing to travel to all camp related events.
Your answer
Zip Code
Your answer
Cell Phone Number
Your answer
Home Phone Number
Your answer
Work Phone Number
Your answer
Email Address
Your answer
Please Confirm Email Address
Please retype email address here for accuracy.
Your answer
Is your household considered a low income household?
Defined as less than $36,375 gross household income per year.
Camper's Ethnicity
Required
Camper's T-Shirt Size
Emergency Contacts
Please list two people, other than the parent or guardian, to contact in case of an emergency. Please include telephone number and relationship to camper.
Your answer
Camper's Pediatrician's Name
Your answer
Camper's Pediatrician's Phone Number
Your answer
How did you hear about Camp Erin Boston?
If you check 'other' please explain.
If you heard about Camp Erin from a person please write that person's name below. If not, please write N/A.
Your answer
Was the deceased a member of the Armed Forces?
Are you (parent or legal guardian) a member of the Armed Forces?
Do you or the camper know anyone attending or applying to Camp Erin Boston (other family members, volunteers, staff or another camper)?
Please specify below. If not, leave blank.
Your answer
Please list any special skills, talents or interests.
Examples: Legos, reading, writing, sports, art, dance, music, favorite subjects in school, etc.
Your answer
Any dietary restrictions, allergies, or preferences?
Please describe below. If none, please write "none"
Your answer
Any allergies? (Stings, medicinal, environmental)
Please describe below. If none, please write "none"
Your answer
Please list ALL medications (over the counter and prescribed) to be administered at Camp.
Specify the name, dose, time to be given and any instructions needed. If none, please write "none"
Your answer
Is the camper up to date on all immunizations and physical exams?
Any difficulties with spending two nights away from home?
If "no", please state "no". If "yes" please explain.
Your answer
Has the camper ever run away from home?
If "no", please state "no". If "yes", please explain.
Your answer
Any inappropriate physical or sexual behaviors we should be aware of?
If "no", please state "no". If "yes", please explain.
Your answer
Has the camper ever discussed or attempted suicide? Caused harm to self or others?
If "no", please state "no". If "yes", please explain.
Your answer
Bereavement History
Name of deceased
Your answer
Relationship to Camper
The deceased is the Camper's:
Required
Date of Death
MM
/
DD
/
YYYY
Cause of Death
Required
Is the camper aware of the cause of death?
Did the deceased receive hospice services?
Age of the deceased at the time of death?
Your answer
Age of the camper at the time of death?
Your answer
Was the camper present at the time of death?
Did the camper attend the funeral or memorial service?
Do you and the camper talk about the loss(es)?
Your answer
Have the camper or any family members received any bereavement counseling?
Has the camper ever been a participant in HEARTplay or worked with Children's Services at CareGroup Parmenter Home Care and Hospice?
Required
Has the camper experienced any other significant deaths?
Please describe. If none, please write "none".
Your answer
Has the camper experienced any other losses or life changes?
This can include pet loss, divorce, illness, moving, changing schools, etc. If none, please write "none".
Your answer
Any additional information about any of the situations or behaviors listed above?
Or, any other questions, comments, or concerns you may have?
Your answer
I certify that all of the above information is correct to the best of my knowledge.
Please type the name of the person who completed this application and his/her relationship to the applicant. This is your DIGITAL SIGNATURE. Example: Mary Jones, parent.
Your answer
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