Family Grief Day Camp Registration

November 9, 2024

10:00am - 2:30pm

The Hive: 2904 E Sprague Ave, Spokane, WA 99202

this form is best filled out using a computer

INFORMED CONSENT

Welcome to Lion's Heart Family Grief Day Camp!

Please read through the information below and feel free to ask your questions about our activities and/or anything about us. Once you are ready to participate, please sign this informed consent form below so we will have on our records that you have read the information and that you have been properly informed about the day camp experience.

EXPECTATIONS

This is not a professional therapy group.
Services are free of charge, and lunch will be provided.
Children ages 5-18 as well as their parents/guardians are invited to participate.
There will be no childcare for younger children available, so please plan ahead.
Please don't come if you're feeling sick or unwell. We want to be ready to play!
Parents/Guardians must stay on-site throughout the program (please, no drop offs of your children).

Family Grief Day Camp is a unique kind of therapeutic group experience, where a group of people who are experiencing a loss gets together to share their difficulties, which as a result give and at the same time, receive help from each other.

We make sure to maintain a safe environment that is conducive both for sharing and accepting each other where each can grow and trust one another, and where each and everyone will feel respected and valued.

Day Camp will be broken up into 3 general age groups: 1. Elementary school-aged children, 2. Middle-School and High-School, and 3. Parents/Guardians. There will be big group games and opening/closing activities. Participants will interact with their peers with specially-trained leaders.

Lion's Heart is staffed by competent grief professionals and their trained volunteers. Day Camp is a fun, therapeutic group, where children and adults will have the opportunity to talk about their experience with loss. Due to the nature of talking about grief, one may have a strong emotional reaction to the activities in camp. Should a participant feel they cannot continue with the activities, they may receive additional support from trained professionals on-site, or they are free to exit at any time.

CONFIDENTIALITY

We respect each and everyone's right to privacy and confidentiality and we shall make sure to maintain it that way. However, please understand that this is not absolute and is limited to provide for by law. Certain limitations are as follows:

Threatening one's self or another that may result in physical harm;
An act of physical or emotional abuse against a child or any person;
Sexual abuse against a child where the child is living with the abuser;
Whenever we are summoned by court order to disclose information against a participant.
Your prior written consent to release records.

CONDUCT AND RELATIONSHIP

It is necessary that the following is required to be complied with by its members:

Discussions made within the group session are not allowed to be discussed outside with anyone and should maintain the practice of confidentiality in order to build trust with fellow members;
Members should maintain positivity and not induce disrespect among others;
Members should not be drunk, nor they are allowed to take alcohol or take drugs before or after day camp;
Maintain conduct that brings respect to fellow members' thoughts, emotions, or behavior;
Refrain from having a relationship with a fellow member other than therapeutic while engaged in the session.

THE LEADERS

The group leaders and volunteers should maintain a professional relationship with the participants at all times, and no more than that. Any relationship with a participant may result in a "dual relationship" and may affect the goals of the session.

CONSENT

I agree to adhere to the norms and expectations for day camp as indicated above. I acknowledge that I have had the opportunity to ask questions and such questions were answered clearly and to my satisfaction.

Signature

Registration Information

Parent/Guardian Contact information

First name

Last name

Email

Phone

Country/Region

Address

City

Zip / Postal code

Emergency Contact

Phone

List names and ages of ALL adults and children who will attend day camp

Please tell us about the loss your family has gone through. Who was the person who died, and how were they related to you?

What was the cause of death?

The death was anticipated (expected)

The death was sudden (unexpected)

When did the loss happen? Date picker

What have you noticed about your child/children since the loss?

For Child #1

For Child #2

For Child #3

For Child #4

Other observations or things we should know:

Do you worry the loss has traumatized your child(ren)?

Yes, the child either witnessed something, was involved somehow, or was deeply affected by the loss, and is displaying worrisome behaviors

No, the child seems to be coping as expected with a difficult loss

I'm not sure and need help assessing this

Other. Please explain

Long answer

Does your family talk openly about the loss/person who died?

Yes, the person comes up a lot

We all tend to avoid the topic

Some of us want to talk about it, some of us don't

What do you tell your children about what happens when someone dies?

Has your child(ren) had any professional grief support?

Therapist

School counselor

Faith leader

Grief group

Grief camp

Does your child(ren) have any current special needs (physical, cognitive, emotional, behavioral? Please explain

Are there any other major stressors in your child(ren's) life that we should be aware of? (new school, move, divorce, additional losses, guardianship issues, etc?)

Is there anything you think your child(ren) will need to be successful at day camp? Any accommodations we can plan for ahead of time?

Do the participants have any food allergies, or need a Gluten Free meal? Please indicate how many Gluten Free meals you need.

Please be aware we will reach out to gather clarifying information and ensure your family knows what to expect with camp.

Waiver Statement:

Assumption of Risk and Waiver of Liability and Medical Authorization

I, as legal guardian of this child(ren) participant in Lion's Heart programs, recognize the potentially severe injuries, including permanent paralysis or death can occur in sports and camp activities. Being fully aware of these dangers, I voluntarily consent to the aforementioned person(s) participating in any and all Lion's Heart Grief Center programs, camps, and activities, and I accept all risks associated with that participation.

I, on my own behalf and the behalf of my child and our respective heirs, administrators, executors and successors, hereby covenant not to sue and forever release Lion's Heart Children's Grief Center, its officers, directors, employees, agents, or volunteers from all liability for any and all damages or injuries suffered by my child while under supervision or control of the Lion's Heart Children's Grief Center programs.

In the event of an accident or emergency, I would like my above mentioned child(ren) to be taken to the hospital for medical treatment, and I hold Lion's Heart Children's Grief Center harmless in their execution of this action. I hereby agree to individually provide for any possible future medical expenses, which may be incurred by my child as a result of any injury sustained while participating in any Lion's Heart Children's Grief Center activity.

I will hold Lion's Heart Children's Grief Center harmless for loss or theft of personal items taken at any program.

By signing, I acknowledge I am the legal guardian for this child and agree to the above.

Signature

Authorization and Photo/Video Release

I authorize Lion's Heart to take my photographs/videos, and to use for our website, social media platforms, and advertising for future events. I agree that all photos and videos are intellectual property rights of Lion's Heart. I agree that I will not receive any monetary compensation for usage of my photographs in social media platforms.

Signature

I decline to authorize photos/videos taken and used for Lion's Heart media purposes.