Fire & Burn Foundation

Embers of Hope Camper Information

Burn Suvivor and Sibling Application

I have read and agree to the information in Camp Cover Letter

Is your child a:

Burn Survivor

Sibling of a Burn Survivor

Is your child a new or returning camper?

New

Returning

Camper Last Name

Camper First Name

What does your child like to be called?

Date of Birth MM/DD/YY

Camper Age

Gender

Male

Female

Address

City

State

Zip

Parent or Guardian Names

Please list both parents or all guardians

Relationship to Camper

Primary Contact Number

Secondary Contact Number

e-mail

Has your child previously attend an overnight camp?

Yes

Has your child previously attended any burn camp?

Yes

Has your child previously attended our winter camp?

Yes

New campers parents/guardians will be contacted after receipt of application with additional questions regarding the campers health, injuries, and/or limitations.

If your child is a returning camper, have there been any significant changes in the child's life, such as changes in the household, behavioral issues, health, new injuries, upcoming or recent surgeries, etc?

Yes

If yes, a Fire & Burn Foundation staff member will be in contact with additional questions. These are essential to providing a safe and healthy camp experience for your child and others.

How did you hear about our camp?

Camper Behavioral Information

Please list any/all mental health diagnosis your child has.

Please describe any fears your child has. (i.e. fear of the dark, heights, etc)

How can we help your child grow and develop?

Is your child struggling with or experiencing any difficulties with their burn injury at this time?

Has your child ever been suspended or expelled from school? If yes, please explain why?

Please tell us about any problems your child is having or has recently had with friends or siblings?

Please tell us about any difficulties your child is now experiencing, in regard to peer pressure, alcohol and/or drug abuse, school adjustment, self-harm, suicidal thoughts, or family illness/crisis.

Has your child been receiving counseling or support for any of the things listed above? If yes, please describe what and when.

Releases and Waivers

Immunization History

Alternate Ride and Contact Consent Form

CAT Consent Form

Photo and Artwork Release

Emergency Medical Release Form

Camper Behavioral Agreement

Consent to Share Complete Application Materials with Sponsoring Organization:

We often host children that other organizations are sponsoring, and periodically applications are submitted to the Fire & Burn Foundation in error. Your signature below will allow us to forward a copy of your child’s completed application to the sponsoring organization.

Please select one:

I consent to the release of my child’s application to their sponsoring organization.

I DO NOT consent to the release of my child’s application to their sponsoring organization.

Date

By signing below I agree that the information contained in this application is complete and accurate to my knowledge. Additionally, I consent for this application to be shared with any organization that sponsored my child's attendance to the Fire & Burn Foundation's Embers of Hope Camp.

Signature

Date

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