Camp Stepping Stones Registration

Grief Support


Step 1 of 4: Guardian & Background Information

If paying by check, please mail to Cammy Adler-Roth, Care Dimensions, 78 Liberty Street, Danvers, MA 01923.

Please correct the errors in red

Attendee Information

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

Guardian Information

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

Background Information

Name of the person who died *
Their relationship to the child *
Their relationship to you *
When did the death occur? *
Age of the child (children) at the time of death *
Age of the person who died *
Did your child live with the person who died?*
Was the person a Care Dimensions patient?*
How did the person die? *
Was your child present at the time of death? If yes, please explain.*
What had your child been told about the death?*
Did your child attend the funeral/memorial service? If yes, what was his/her reaction?*
Please explain any specific concerns or important information about your child's behavior since the dealth has occurred. Include any difficulties coping, fears/worries, aggression or isoloating behaviors, changes in personality, etc. Please include information for each child attending.
Has your child 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.
(** indicate break between choices)Temporary or extended separation of parents or divorce
Diagnosed with special needs, learning disability, illness
Prolonged illness of a family member or close friend
Death of a pet
Moving to a new home, school or neighborhood
Parent/caregiver marriage/remarriage
History of physical/emotional abuse
Change in routine, caregivers or adult role models
Break-up of friendship or boyfriend/girlfriend
Failing a class or grade in school
Being the victim of a crime
Going into foster care or moving to a new foster care home
Consistently difficult relationship with siblings, parent/caregiver, teachers
Unplanned job loss of a parent or caregiver
Arrival of a new family member (birth, adoption, new person) into the home

Thank you for helping us to understand your child's circumstances better. All information is confidential and will only be shared with the camp counselors and volunteers under the guidance of the Children's Program Coordinator.

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 more than 90 communities in Eastern Massachusetts.