CAMP AMANDA
CHILDREN and TEENS AGES 6 TO 17
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 a camp date:

Today's date:    
Child's last name: Parent's last name:
Child's first Name: Child's Birthdate:
Child's Age: Child's Address:
City: County:
State: Zip Code:
* Home Phone: Work Phone:
Emergency Phone: * E-mail:
Child's T-shirt Size: School and grade:


Name wished to be printed on name tag, if other than formal given name:
First and last name of person who died:
Relationship to camper:
Birthdate of person who died:
Cause of death:
Age at time of death:
Date of death:
Did camper witness the death?
If you answered "Yes" to the previous question, please explain further:
Did camper live with the person who died?
Please describe camper's relationship with the person who died:
Specific concerns or pertinent information such as inappropriate or aggressive behaviors or incidents, re-marriage, relocation of camper after death to another community, additional losses, difficulty in school or in relationships with others, etc. Please explain.
How did you hear about Camp Amanda? Were you referred by a friend, school, funeral home, hospice, etc.? Please state the name and town where located, and the name of the specific person who referred you, if you know it.
What are your expectations of Camp Amanda?
Please describe your child/teen's personality, character traits, likes/dislikes, hobbies, etc.:
List names, ages, and birthdates of other children and adults living in your home:
Has your child been in any support groups or counseling?
If you answered "Yes" to the previous question, please explain.
Any health problems, allergies, medications?
Amanda Cares, Inc. has my permission to use any photos taken of my child at Camp Amanda for brochures, slide shows, etc.
Amanda Cares, Inc. has my permission to treat my child with emergency medical care, if necessary.
Relationship of person completing this form to camper:
Parent or Guardian's Full Name:
Parent's Occupation:
Employed by:
Are you attending Parent Camp this weekend?


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 never a fee to those who attend. To reserve your 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. Your check or money-order will returned to you uncashed, if you attend. If you do no attend camp after you have registered, your reservation deposit is forfeited. For your application to be processed, we must receive an application form for each person, a recent photo (for security purposes) and your refundable deposit. Incomplete applications will not be processed.



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 refundable 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
jzpanda@aol.com www.AmandaThePanda.org