be cs application and forms april...

Toll-free: 888.848.5200300 Northpointe Parkway, Suite 305 • West Palm Beach, FL 33407

Camp Application

300 Northpointe Parkway, Suite 305 • West Palm Beach, FL 33407 • Toll-free: 888.848.5200Accredited by The Joint Commission. 501(c)(3) not-for-profit organization.

Dear Parent or Guardian:

We are pleased to announce that The Sea Star Program’s Camp Stingray is open to grieving children, age 5-11, grades K-5. The camp will run from Monday, June 9th through Friday, June 13th, 2014 at Royal Palm Beach Commons.The purpose of Camp Stingray is to bring children whose loved ones have died together for support and friendship. We will provide an environment that is safe and fun as they participate in sharing their stories, music, art, outdoor activities, games, and organized cooperative sports.

Camp Stingray provides a new support system to children who are grieving the loss of a loved one. Throughout the week, campers will have an opportunity to:

• Identify ways to cope with change• Improve self-esteem• Learn to recognize and validate feelings• Identify safe ways of grief expression• Recognize that having fun and celebrating are still a part of life

The Sea Star Program’s Camp Stingray is free for all campers. Please complete the attached application for your child. Following receipt of the application, you will be contacted by our bereavement staff to further assess eligibility.

Please direct any questions to Christina Dekkar at (561) 227-5175.

Applications must be received by May 23, 2014. Applications may be faxed to (561) 273-2267 attn: Christina Dekkar, or mailed to Hospice of Palm Beach County Brogan Bereavement Center, Christina Dekkar, 300 Northpoint Parkway, Suite 305, West Palm Beach, 33407.

Space is limited - be sure to return your paperwork by May 23, 2014.

Sincerely,

Children’s Bereavement Counselors

Hospice of Palm Beach County and Broward County & Hospice by the Sea


Camp ApplicationName: _____________________________________________________________________________

Address: ____________________________________________________________________________

Phone number: _____________________________________________________________________

Email address: ______________________________________________________________________

Date of Birth:_____________________________ Male Female

School: ____________________________________________________________________________

Grade: __________________________________

Does the child have an Individual Education Plan (IEP) or a 504 Plan? Yes No

Does the child have a medical condition or disability that we need to know about?

Yes No ____________________________________________________________________

What medication does your child take?

___________________________________________________________________________________

Name of the deceased:

Relationship to the child: ____________________________________________________________

Date of Death:

Cause of Death:

Was the child present at the time of death? Yes No

Did the child see the deceased after the death? Yes No

Did the child attend the funeral or memorial services? Yes No___________________________

Do you and the child talk about the deceased? Yes No___________________________


Did the child receive counseling/grief support services before or after the death? Yes No

Describe the relationship between the child and the deceased:

How did the child react to the death?

Has the child experienced any other deaths? Yes No

Describe any other changes/stresses in the child life (e.g. divorce, illness, moving).

Has the child said or done anything recently that concerns you?

Has the child expressed any concerns to you recently?


Has the child exhibited any of the following behaviors since the death? (check all that apply)

Depression

Run away from home

Suicidal thoughts

Harmed self/Harmed others

Harmed animals

Unusual/ inappropriate sexual behavior

Drug/alcohol abuse

Lying

Regression

Behavioral problems (home and school)

Stealing

Nightmares

Destruction of property

Ongoing sleep disturbance

What if any concerns do you have about the child coming to camp?

Parent/Guardian Signature Date

Print Parent/Guardian name___________________________________________________________

Please contact Christina Dekkar with any questions or concerns (561) 227-5175


What do I need to bring?Please bring a bagged lunch. We provide water and snacks

Put sunblock on camper berfore arriving camp

Toiletries

Insect repellent

Lip balm

Sunblock

Clothing

Two (2) extra pair of clothes

Bathing suit

Towel

Extra towel or blanket to sit on

Headgear

Hat

Hair ties or barrettes

Sunglasses

Footwear

Sneakers

Water shoes / Flip � ops

Socks (extra)

Campers are NOT to bring any other belongings such as: money, jewelry, cell phones, i-pods, radios etc. We cannot be responsible for personal belongings that are brought into camp without permission.

No drugs or weapons are to be brought into the camp under any circumstances.


Permissions and Releases(Initial on all lines) Medications/First Aid

I give permission to the Camp Stingray staff to administer � rst aid to my child. I also give my permission to Camp Stingray to take my child to the nearest hospital in the event of an emergency.

Liability statementIn consideration for allowing my child to participate at Camp Stingray, I, for myself and child, release and forever discharge Hospice of Palm Beach County, Hospice of Broward County and Hospice by the Sea its directors, of� cers, employees, volunteers and agents of all liabilities, claims, actions, damages, costs or expenses which I or my child may have against them arising out of or in any way connected with my participation or my child’s participation in this program, including travel to or from the program and including injuries which may be suffered by my child before, during, or after the program.

Authorization to photograph/interview/tapeI hereby give my permission for my child’s photo and/or name to be utilized and released for educational, public relations/media purposes, presentations, camp video or brochures

Water sports

I give my child permission to participate in water sports (e.g. going in fountain) while attending Camp Stingray under supervision.

I have read and understood all of the above information and authorize my child to participate in the Camp Stingray grief camp for children of JOHN J. BROGAN BEREAVEMENT CENTER, a program of HOSPICE OF PALM BEACH COUNTY, HOSPICE OF BROWARD COUNTY AND HOSPICE BY THE SEA.

Parent/Guardian Name (Printed): ______________________________

Signature of Parent/Guardian: _________________________________ Date:_________________

Please attach a small photo of your child to this form. Of� ce use only.


Discipline ProtocolIn order to provide and maintain safety for all campers and in consideration for our entire camping staff, campers are expected to follow and to obey all Camp Stingray rules.

The following progressive discipline protocol will be used for any behavioral or out-of-control issues:

1st incident: VERBAL WARNING/REDIRECTION AND COUNSELING

2nd incident: TIME-OUT FROM GROUP ACTIVITY/COUNSELING

3rd incident: CALL PARENT OR GUARDIAN TO PICK UP CHILD

NOTE: If a camper requires medication to control behavior, all efforts must be made to maintain the child/teen on prescribed medications as prescribed by a physician.

I have read, explained and reviewed the discipline protocol to my child. I understand my responsibility to pick up my child in the event of his/her participating in excessive uncontrolled behaviors.

Name of Child (Printed): ________________________________ Date: _________________

Name of Child (Printed): ________________________________ Date: _________________

Parent/Guardian Name (Printed): ________________________________________________

Parent/Guardian Signature: _____________________________ Date: _________________


Schedule

Date Drop off Time Pick up TimeMonday, June 9, 2014 9:00 am 4:00 pm

Tuesday, June 10, 2014 9:00 am 4:00 pm

Wednesday, June 11, 2014 9:00 am 4:00 pm

Thursday, June 12, 2014 9:00 am 4:00 pm

Friday, June 13, 2014 9:00 am 4:00 pm

The Sea Star Program’s Camp StingrayThe Stingray moves gracefully through the ocean, despite the currents. In grief, we can feel challenged to stay a� oat in an ocean of dif� cult emotions. The stingray teaches us to glide through the watery depths of grief with gentle persistence to � nd expression, growth, and healing.

If you have any emergencies during camp time, contact number below:Christina Dekkar LCSW

Childrens Bereavement CounselorCell: 561.315.0240

Camp Address:Royal Palm Beach Commons11600 Poinciana Blvd.Royal Palm Beach, FL 33411

Map & Directions


Map & Directions

704

80

From North (I-95 or Turnpike)Exit at Okeechobee Boulevard and head west. Turn LEFT onto Royal Palm Beach Boulevard. Turn LEFT onto Poinciana Blvd. The Sports Complex will be the large building on the right.

From South Turnpike:Exit at Southern Blvd. Turn LEFT on Pike Rd. Turn RIGHT onto Southern Blvd.Turn RIGHT onto Royal Palm Beach Boulevard. Turn RIGHT onto PoincianaBlvd. The Sports Complex will be the large building on the right.

I-95:Exit at Southern Blvd. and head west. Turn RIGHT onto Royal Palm Beach Boulevard. Turn RIGHT onto Poinciana Blvd. The Sports Complex will be the large building on the right.

Camp Address:Royal Palm Beach Commons11600 Poinciana Blvd.Royal Palm Beach, FL 33411

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