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Camp Stepping Stones Registration

Step 1 of 4: Guardian & Background Information

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Attendee Information

Number of Campers Attending :*
Adults Attending, besides Yourself:*

Guardian Information

First Name:*
Last Name:*
Pronouns Used:
Relationship to child:*
Address 2:
State :*
Home Phone:*
Cell Phone:
Work Phone:
Email Confirm:*
Preferred contact:*

Background Information

Name of the person who died*
Their relationship to the children*
Their relationship to you*
When did the death occur?*
Age of the children at the time of death*
Age of the person who died*
Did your children live with the person who died?*
Was the person a Care Dimensions patient?*
How did the person die?*
Were your children present at the time of death? If yes, please explain.*
What have your children been told about the death?*
Please explain any specific concerns or important information about your children's behavior since the death has occurred. Include any difficulties coping, fears/worries, aggression or isolating behaviors, changes in personality, etc. Please include information for each child attending:
Have your children experienced any other deaths? If yes, please list who and when.*

The following events could also be associated with, or can complicate, a loss. Please check all that apply. If any of these pertain to a specific child, please detail the issues in the notes section below.

Thank you for helping us to understand your child's circumstances better. All information is confidential and will only be shared with Camp Stepping Stones staff.

Since 1978, Care Dimensions has provided comprehensive and compassionate care for individuals and families dealing with life-threatening illnesses. As the non-profit leader in advanced illness care, we offer services in over 100 communities in Massachusetts.

Copyright 2023 | Care Dimensions, 75 Sylvan Street, Suite B-102, Danvers, MA 01923 | 888-283-1722 | 978-774-7566

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