Journey of Hope Camp Application "*" indicates required fields Parent/Guardian Information:Name* First Last Date of Birth* Month Day Year Race*Spouse Name* First Last Spouse Date of Birth* Month Day Year Spouse Race*Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Phone Type Mobile Home Other Email* About the Camper:Camper Name* First Last Age*Grade*Camper Date of Birth* Month Day Year Camper Race*Adopted?* Yes No Type of Adoption* International Domestic Foster Care When?* Month Day Year From Where?*Care Environment 1*Type of care prior to adoption (i.e. foster care, orphanage, group home, etc.):Age at Entry*Duration*Care Environment 2Type of care prior to adoption (i.e. foster care, orphanage, group home, etc.):Age at EntryDurationCare Environment 3Type of care prior to adoption (i.e. foster care, orphanage, group home, etc.):Age at EntryDurationHas your child experienced any of the following: A difficult pregnancy A difficult birth Early hospitalization Neglect Physical abuse Sexual abuse Loss of primary caregiver Other Trauma Please Explain the difficult pregnancy:*Please Explain the difficult birth:*Please Explain the early hospitalization:*Please Explain the neglect:*Please Explain the physical abuse:*Please Explain the sexual abuse:*Please Explain the loss of primary caregiver:*Please Explain the other trauma:*Additional CommentsOther Children in the HomeDo you have other children in the home?* Yes No Please indicate the number of Adopted ChildrenPlease indicate the number of Biological ChildrenWill you be applying for multiple children to attend camp?* Yes No Medical InformationName of Family Physician* Prefix Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Last Physician's Phone*Insurance Provider*Group #*Front*Please upload a copy of the front of the insurance CardAccepted file types: jpg, png, bmp, Max. file size: 256 MB.Back*Please upload a copy of the back of the insurance CardAccepted file types: jpg, png, bmp, Max. file size: 256 MB.Does your child currently have or previously had any of the following?Please check the box to indicate yes, fields for explanation will be displayed below. Any medical or physical diagnosis? Any known allergies or food restrictions? Any limiting physical difficulties? Any psychological diagnosis (e.g. ADD/ADHD, Autism, ODD, etc.)? Hospitalizations for a serious injury (e.g. broken bones, head trauma, etc.)? Hospitalizations of significant illness (e.g. pneumonia, asthma, etc.)? Hospitalizations for behavioral or emotional problems? Name the medical or physical diagnosis:*Date of medical or physical diagnosis* Month Day Year Please list current medications for the medical or physical diagnosis:*Please Explain the allergy or food restrictions:*Please Explain the limiting physical difficulties:*Please name the psychological diagnosis:*Date of the psychological diagnosis:* Month Day Year Please list medications for the psychological diagnosis:*Please Explain the hospitalization or serious injury:*Please Explain the hospitalization for significant illness:*Reason for hospitalization due to behavior or emotional problems:*Date of hospitalization for behavior or emotional problems:* Month Day Year Please list current medications for behavior or emotional problems:*Additional comments about health:BehaviorDoes your child have any of the following difficulties?Please check yes to indicate difficulty. Behavioral Emotional Educational Sensory Societal Please explain behavioral difficulty:*Please explain emotional difficulty:*Please explain educational difficulty:*Please explain sensory difficulty:*Please explain societal difficulty:*Additional comments regarding behaviorHave you ever worried about the physical safety of your child or others around your child because of the emotional or behavioral difficulties your child may be experiencing?* Yes No Please explain your concern regarding the physical safety of your child or others:*Has your child ever harmed or attempted to harm another person, animal, or themselves?* Yes No Please describe when your child harmed themselves or others:*What are your child’s major strengths?*What are your child’s major difficulties?*What qualities in a one-on-one "buddy" would match well with your child (ex. high energy, playful, calming presence, same race (if possible))?*Please list three goals that you have for your child during camp.*Family Strengths, Difficulties & HopesWhat are your family’s major strengths?*What are you family’s major difficulties?*What does your family hope to gain from coming to camp?*As parent(s), what are your major strengths?*As parent(s), what are your major difficulties?*Please list three goals that you have for yourself during camp.*Family Photo*Please upload a family photo.Accepted file types: jpg, png, bmp, Max. file size: 256 MB.Multi-child ApplicationsWill you be applying for more than one child to attend camp?* Yes No How many children?*NameThis field is for validation purposes and should be left unchanged. 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