Camper Registration Request Form

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1. Parent/Guardian Information

Parent/Guardian Information Name:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

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2. Camper Information (Name, Age, Gender)

Camper Information (Name, Age, Gender) Camper #1
Camper #2
Camper #3
Camper #4
Camper #5

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3. Name of the Deceased and relationship to camper(s).

Name of the Deceased and relationship to camper(s).

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4. What was the age of the child(ren) at the time of death?

What was the age of the child(ren) at the time of death?

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5. How did you hear about this program?

How did you hear about this program? Providence Hospice

Other Hospice Program

School

Physician

Friend

Newspaper/Radio/TV

Other

Other (please specify)

6. I am interested in receiving a Camp Erin
application. Please send me enough for my child(ren).

I am interested in receiving a Camp Erin application. Please send me enough for my child(ren). 1

2

3

4

5

Thank you for your interest in Camp Erin. By clicking the "done" button below, we know to send your application packet(s) shortly. All campers are required to have a completed application in order to be considered for a camp placement, but we cannot guarantee that every camper with a complete application will be invited to camp. Once we receive a completed application, we will contact you with any follow up questions we may have. You may then be invited to attend a family information night with your camper(s).

Camp Erin will take place this year on August 28th-30th in Boring, OR.