CAMP AMANDA
ADULT CAMP
REGISTRATION FORM

  
A separate form must be filled out for each person attending camp. After completing this form, click the "Send Application" button below. All applications will be processed only when the following (3) items are received:
1. Application Form
2. Recent Photo
3. $35.00 Registration Deposit per Person (Refundable)

Incomplete registrations will not be processed

PLEASE DO NOT PRINT THIS FORM


Please choose one of the following camp dates:

Last Name: First Name:
Today's Date: Birthdate:
Age: Address:
City: County:
State: Zip Code:
* Home Phone: Work Phone:
Emergency Phone: * E-mail:
Employer: Occupation:
T-shirt Size:
Name you wish printed on camp nametag, if other than formal given name:
Names and ages of children/teens attending camp:
First and last name of person who died:
Relationship to you:
If husband or wife died, please indicate if you were married or divorced at time of death:
Birthdate of person who died:
If spouse died, date and year of wedding anniversary:
Cause of death:
Age at time of death:
Date of death:
Did death occur at home, hospital, or other?
Were you present at time of death?
Was this person living at home, away at school, outside the home, separated, divorced, etc.?
Who or what has helped you most since the death and in what way? Family, friends, church, spouse, others?
What kinds of support do you now have now?
Describe your greatest concern at this time: children, concentration, loneliness, other:
Are you concerned about job security or finances at this time?
What are your concerns and/or needs at this time?
How would you describe your family's communication around the death?
What are your expectations of Camp Amanda?
Please tell us about your interests (i.e. hobbies, sports, reading, crafts, cooking):
How did you hear about Camp Amanda? Were you referred by a friend, school, funeral home, hospice, etc.? Please state the name and town of the school, funeral home, etc. and the name of the specific person who referred you, if you know it.
Any health problems, allergies, medications?
Amanda Cares, Inc. has my permission to:
Use any photos taken at Camp Amanda:

Have me treated for medical care as needed, if necessary:

List names, ages, and birthdates of other children and adults living in the home:


The information you submit to Amanda the Panda will be kept strictly confidential. See our Privacy Policy for further information.


         

The cost of Camp Amanda is $500 per person, which includes follow-up support for one year. Camp scholarships are available so there is no fee to attend. To reserve you space at Camp Amanda, we require a refundable $35 camp reservation deposit per person - not to exceed $100 per family living at the same address, a recent photo, and a completed application form for each person. Incomplete applications will not be processed. Your check or money order will be returned to you uncashed, if you attend. If you do not attend camp after you have registered, your deposit is forfeited.


Space is limited and registrations are accepted in the order received. Apply early to ensure availability. Please mail a recent photo of each applicant and your deposit to:

JoAnn Zimmerman, Camp Director, Camp Amanda, 1000 73rd St. Suite 12, Des Moines, IA 50311

PLEASE NOTE: The Adult Camp and the Children's/Teen camp are entirely separate camps. Children and teens will be sleeping in separate cabin's from their parents. Married couples will also be sleeping apart due to limitations of cabins and bunk beds.




Phone (515) 223-4847 FAX (515) 223-4782
1000 73rd St. Suite 12 Des Moines, Iowa 50311
info@amandathepanda.org www.AmandaThePanda.org