2018 Camper Application Camp Erin Boston
There will be one session of Camp Erin Boston in 2018.


Camp Erin Boston Session will be held
Friday, August 17, 2018 through Sunday, August 19, 2018
at Camp Avoda in Middleboro, 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.

APPLICATIONS ARE DUE BY JUNE 1, 2018.

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 March-June 2018. 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 in Mid-July 2018. Date and place TBA

- A Reunion will be held in Mid- October 2018. Date and place TBA
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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.

Camper's First Name *
Your answer
Camper's Last Name(s) *
Your answer
Camper's Date of Birth *
Your answer
Camper's Age *
Age camper will be by August 17, 2018
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 choose '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. You can look for a Camp Erin in your state at www.moyerfoundation.org .
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
Email Address- please confirm *
Your answer
Is your household considered a low income household? *
Defined as less than $36,900 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 heard about Camp Erin from a person/school/organization please write the name of the person/school/organization below. If not, please write N/A. *
Your answer
Are you (parent/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 or write No.
Your answer
Please list any special skills, talents or interests of the camper. *
Examples: Legos, reading, writing, sports, art, dance, music, favorite subjects in school, etc.
Your answer
Any dietary restrictions, food allergies, or preferences? *
If none, please write "none".
Your answer
Any Allergies? (Stings, Medicinal, Environmental?) *
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 staying away from home for two nights? *
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 and/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
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