Refer a Child to Camp Evergreen

logo_Camp-Evergreen_Revised-1

Presentation1

Do you know a child who has suffered a significant loss of a loved one?  Camp Evergreen is a four day summer camp that provides a safe, healthy, supportive and accepting atmosphere for youth to share their experiences and feelings associated with the death of their loved one.  The camp is provided free-of-charge thanks to the support of our community.  Space is limited so each youth is screened by our Camp Counselor and priority is given to new applicants or those children who have a higher level of complicated grief.

Important for 2017

* Priority is given to first time campers. *

Please have all camper referrals made by:

July 21, 2017

Camp Evergreen Staff will mail applications to campers by:

July 24, 2017

Applications must be returned to Klamath Hospice by:

August 4, 2017

 

Your name:*

Phone number: *

Email:

How do you know the camper? *

Camper name: *

Camper gender: *
malefemale

Camper age: *

What school does your camper attend?

First time camper? (required)*
yesno

If no, what year(s) did he/she attend camp? Priority is given to first time campers.

Relationship of the deceased to the camper:

How long ago was the loss?

Parent or Caregiver Name: *

Relationship to camper:

Caregiver phone number: *

Email:

Address: *

City: *

State: *

Zip: *

Additional comments: