Child Application Form

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Child's Last Name: Child's First Name:
Preferred Name (used for Name Tags) T-Shirt Size
Age of Child : Mailing Address :
City : State :
Phone Number : Zip Code :
Sex : Male Female Date of Birth : DD MM YY
Email : Spoken Language:
Name of Parent or Guardian : Relationship to Child :
Emergency Contact Name : Emergency No. :
What family members live with the child? If other children please list ages:
Name of Person(s) : Relationship to Child :
Date of Death : DD MM YY Cause of Death :
Did the child live with this person?   Yes    No Did the child witness the death?   Yes    No
 
Please describe any and all previous or ongoing services for this child. Psychological/Counseling/School Counseling.
The following information is very important to us in pairing the child with the appropriate buddy, to inform our counselors with as much information as possible and to prevent inconveniencing you with long phone calls; therefore we appreciate your being as specific as possible.
What particular, current emotions are you seeing in the child?
Sadness Anger Guilt Lonliness Other
Please describe when and how you see these emotions
(please be as specific as possible).
Please list all Medications the child is currently taking?
Name of Medication :
Dosage :
Time each day to be given?
Please list any physical limitations and describe fully:
Has the child been sleeping since the death? Yes No
Has the child had nightmares since the death? Yes No
Comments:
Describe the child's appetite and eating habits since the death:
What specific behaviors and changes have you observed since the death?
Please describe any social changes your child has shown since the death.
What behavioral issues are you experiencing?
Please explain any profound changes in your child's grades or school behavior.
What special services, if any, does your child's school provide?
Please list any other concerns you feel we should be advised of.
What areas would you like to see improvement in your child?
Why did you choose Camp Agape?
How did you hear about Camp Agape?
Date Submitted:
(DD/MM/YY)
  
Upon receipt of your application you will receive an e-mail confirmation. If you have any questions please contact us at 830-385-8916.
  
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