Camp Application

Our bereavement counselor will contact you to schedule a screening.

Call (800) HOSPICE ((800) 467-7423) for help with this form or for phone RSVPs

I am interested in:

Camp Coral-Broward
Camp Erin-Miami
Camp Coral-Monroe

Camper’s Full Name

Date of Birth Sex Age Grade

Home Address

City Zip State

Name of Parent/Legal Guardian

Home Phone

Cell Phone

E-mail

Name of School

Name of School Counselor

Name of Deceased

Date of Death

Relationship to Camper

Was the death anticipated?

Cause of Death