Camp Comfort Application

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If this application is for a new camper, it will take approximately 20 minutes to fill out. If this application is for a returning camper, it will take approximately 10 – 15 minutes to fill out. Thank you for taking the time to provide accurate and detailed information about your child!

How did you hear about Camp Comfort?(Required)

Please be specific! Indicate if the referral came from a school, person, organization, internet search, etc.

Camper Demographic Information

Camper Name(Required)

First Last

Name for Name Tag(Required)

First

Camp Session Interest(Required)

June Weekend Camp: June 14 – 16, 2024

July Weekend Camp: July 12 – 14, 2024

July Day Camp: July 23 – 25, 2024

Camper T-Shirt Size(Required)

Camper Date of Birth(Required)

MM slash DD slash YYYY

Camper Age at Camp(Required)

Camper grade 2024-2025 school year:(Required)

What school does the camper attend?

Camper race

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Pacific Islander

Multiracial

Other

Camper Sex(Required)

Male

Female

Other

Camper Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Information. Click the plus sign at the end of the line to add a second Parent/Guardian(Required)

First Name

Last Name

Relationship to Camper

Email Address

Phone Number

For Relationship: Mother, Father, Grandparent, Aunt, Uncle, Foster Parent, Sibling, etc.

If someone other than the parent/guardian listed above were to pick up my child at the end of the camp session, such person must present identification upon pick up. I do hereby authorize the following to pick up my child:

Name

Relationship

Phone Number

Grief History

Name of the person who died(Required)

Relationship to child(Required)

If other was selected, please state relationship here:

Date of Death(Required)

MM slash DD slash YYYY

Age of person who died(Required)

Child's age at time of death(Required)

Cause of death(Required)

Is your child aware of the cause of death?(Required)

Describe their awareness(Required)

Did your child attend the funeral/memorial service?(Required)

How does your child show their grief?(Required)

Are there any spiritual or cultural beliefs that have supported your child in their grief?(Required)

Has your child experienced any additional changes or stressors within the last year? (check as many that apply)

Moved houses

Moved schools

Parent/guardian changes in jobs

Court case

Birth of a sibling/child addition to the family

Divorce/adult separation

Change in primary custody of child

Financial stress

Child illness/diagnosis

Death of a pet or other close person

Other

Indicate other changes/stressors here:

Is your child currently receiving therapy or counseling?(Required)

Yes

If applicable, explain current/ past therapy or counseling:

Additional information regarding your child's grief experience. (Optional)

Health History

Physical Health History (Check all that apply)

Allergies: Food

Allergies: Seasonal

Allergies: Medical

Allergies: Animals

Asthma

Constipation

Convulsions

Diabetes

Ear Infections

Epilepsy

Enuresis (frequent urination involuntary and or voluntary)

Encopresis (frequent bowel movements involuntary and or voluntary)

Fainting

Heart Condition

Hepatitis B

Hepatitis C

Hearing Impairment

Kidney Disease

Motion Sickness

Menstrual Cramps

Nosebleeds

Physical Disabilities

Sleeping Difficulties/Bedwetting

Sleep Walking

Wears: contacts/glasses

Other

No physical health conditions apply

Indicate other here:

For all boxes selected, please elaborate.

Does your child have any dietary restrictions?(Required)

Yes

List dietary restrictions here:

Mental Health History (check all that apply)

Autism Spectrum Disorder

ADD/ADHD

Behavioral Condition (Oppositional Defiance, Conduct Disorder, etc.)

Developmental Delays

Emotional Condition (Anxiety, Depression, Mood Disorder, etc.)

Individual Education Plan (IEP)

Learning Disabilities

Tourette Syndrome

Other

No mental health conditions apply

Indicate other here:

For all boxes selected, please elaborate.

Will your child be taking medication while at camp?(Required)

Yes

Unknown at this time

List all of your child's medications below. Include dosage and time given.

Is your child current with immunizations?(Required)

Yes

Unsure

May Camp Comfort administer the following medicine, if your child is experiencing associated symptoms? (Check all that you agree to being administered)

Children’s Motrin (for headaches and body aches)

Children’s Tylenol (for headaches and body aches)

Children’s Benadryl (for allergy symptoms)

Cough Drops (for irritated or sore throat)

Does your child have any physical conditions and or injuries that would restrict any camp activities (swimming, climbing, running, etc.)(Required)

Yes

If yes- please provide more detail:

How is your child's swimming ability?(Required)

Tell Us More About Your Camper

Is your child new or returning to Camp Comfort?(Required)

How do you think your child will do in a small therapy-based group for 1 to 1.5 hours at a time?(Required)

Does your child need any extra emotional, physical and/or behavioral support? Camp Comfort staff & volunteers are trained to support all children and information on this section will help with preparing for and supporting your child.(Required)

If yes – please explain how to best support your child:

Select the boxes below that best describe your child.(Required)

Quiet, reserved

Talkative

Active, high energy

Calm

Internalizes Emotions

Externalizes Emotions

Slow to Warm

Outgoing

Worries

Enjoys group activities

Enjoys one-on-one

Easily frustrated or angered

Night owl

Tires easily

Adaptable, flexible thinker

Rigid thinker

Please describe other personality traits that would be helpful for us to know about your child:(Required)

How will your child do sleeping away from home? Will they need any special accommodations?(Required)

What year did your child attend Camp Comfort?(Required)

Have there been any significant changes in your child's interests/activities, behavior, emotional response or personality since they last attended Camp Comfort? If so, please indicate here. If no significant changes, information from their previous application will be used in the matching process with your child's adult buddy and peers.(Required)

Please describe any concerns your child has about attending Camp Comfort this summer:(Required)

List your child's current interests, activities involved in and/or activities they like to do in their free time:(Required)

Releases & Signature

Photo Release (Minor Child)(Required)

Yes, I do give permission for my child to appear in publicity or social media in relationship to Camp Comfort and marketing efforts.

No, I DO NOT give permission for my child to appear in publicity or social media in relationship to Camp Comfort and marketing efforts.

Risk Release(Required)

I agree to the risk release.

In consideration of my child’s participation in Camp Comfort, I, for myself and my minor child, release and discharge Mount Evans Home Health Care & Hospice (referred to as, “Mount Evans”), its agents, employees and volunteers, from any and all claims demands, or actions which I, or my child ever had, or may in the future have against Mount Evans, its agents, employees and volunteers for all personal injuries, either physical or emotional, known or unknown and injury to property, real or personal, sustained by my child’s person or property during their attendance at Camp Comfort unless such injury or damage is due to the negligence or intentional misconduct of Mount Evans, or one of its personnel listed above. I specifically release and discharge Mount Evans and all those listed above from any claim that it or they were negligent in the selection of Easter Seals Colorado – Rocky Mountain Village (weekend camp) as the operators of the facilities of the camp. I understand that outdoor activities carry with them certain associated risks including the risk of physical injury. I accept those risks, for myself and my child as part of the camp experience.

Health Release(Required)

I agree to the health release.

The health history included in this application is correct as far as I know.
– I give permission to Camp Comfort/Mount Evans staff to share the information contained in this application with the volunteers who will be working with my child. I give my permission to administer the above-noted medications and/or first aid to my child. I also give permission for the Camp Comfort/Mount Evans staff to obtain emergency medical care, including transportation for my child if I cannot be reached by telephone for consent.
– I agree not to send my child to Camp Comfort if they has been ill or exposed to a contagious disease and to notify Camp Comfort/Mount Evans staff if this situation arises. Please sign above, agreeing to the health release.

Parent/Guardian Signature for Releases

Payment

Payment Plan Selection

The preference is that the registration fee is made with a credit card on this application. If a different payment plan is needed, please indicate below – thank you!

Pay by credit card on this application

Pay later with cash or personal check

Submit credit card information via phone (call the office at 303-674-6400)

Submit a scholarship request

Other

Camper Registration Fee Quantity

Price: $25.00

Quantity

Indicate the number of campers being paid for in the quantity box. The price will go up by increments of $25 per camper. This fee is non-refundable and is the only payment required to participate at Camp Comfort. If registering more than one camper, for convenience, you can pay for all campers on one application and then skip payment on the proceeding application(s).

Generous Donation

If you are able and would like to contribute funds exceeding the required $25 camper fee, we greatly appreciate your financial support! Contributions will go directly towards camper costs and will help ensure a free camp for all families this year and years to come. Thank you so much!

Total

Credit Card(Required)

Cardholder Name

Card Details

Name(Required)

First Last

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Confirmation Email(Required)

Please let us know where you’d like us to send an email notification that your application has been successfully submitted.

Scholarship request

Please tell us about your situation, and how a Camp Comfort scholarship would benefit your family and financial situation.

Camp Comfort Application

Camper Demographic Information

Grief History

Health History

Tell Us More About Your Camper

Releases & Signature

Payment

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Sign up for our Monthly Newsletter.

THANK YOU FOR YOUR INTEREST IN SUPPORTING
MOUNT EVANS!

IMPORTANT NOTICE

Camp Comfort Application

Camper Demographic Information

Grief History

Health History

Tell Us More About Your Camper

Releases & Signature

Payment

Stay Informed... Sign up for our Monthly Newsletter.

THANK YOU FOR YOUR INTEREST IN SUPPORTINGMOUNT EVANS!

IMPORTANT NOTICE

Stay Informed...
Sign up for our Monthly Newsletter.

THANK YOU FOR YOUR INTEREST IN SUPPORTING
MOUNT EVANS!