CAMP AMANDA

       CAMP FOR COLLEGE STUDENTS

              REGISTRATION FORM        

            JANUARY 10-11, 2009

COLLEGE STUDENTS

AGE 18-23

  

A separate form must be filled out for each person attending camp. Feel free to duplicate this form as needed.

Please complete this application in ink. All applications will be processed only when the following (3) items are received.

1.                   Application

2.                   Recent photo

3.                   $35.00 registration deposit per person (Refundable).

Incomplete registrations will not be processed

PLEASE DO NOT PRINT THIS FORM
Last Name: First Name:
Today's Date: Birthdate:
Age: Name of College
Residence Address: City:
County: State:
Zip: College Phone #
Email: Home Address:
City: County:
State: Zip:
Home Phone: Emergency #:
T-shirt Size:
First and last name of person who died:
Relationship to you:
Birthdate of person who died:
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?
Who or what has helped you most since the death and in what way? Family, friends, church, school, others?
What kinds of support do you now have now on campus?
If none, what kind of support would you like from your school, RA, peers, etc?:
What are your concerns and/or needs at this time?
How would you describe your family's communication around the death?
Describe your college peers, roomate, RA's, etc. communication around the death:
What are your expectations of Camp Amanda?
Please tell us about your interests (i.e. hobbies, sports, reading, educational):
How did you hear about Camp Amanda? 
Any health problems, allergies, medications?
Do you have a younger brother or sister aged 6-17 living at home who might like to attend our children/teen camp?
If yes please list name, age and birthdate:


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


         

There is no fee to attend Camp Amanda, only a token reservation deposit which is totally refundable.

To reserve your space at Camp Amanda, we require a refundable $35 camp reservation DEPOSIT per person. 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 reservation deposit is forfeited. Four your application to be processed, we must receive an application form, a recent photo (for security purposes), and your refundable deposit. Incomplete applications will not be processed.

Apply early. Please make every effort to mail your completed registrations form(s) and a $35 deposit as soon as possible. 

Mail to: Charlie Kiesling, Camp Amanda, 1000 73rd St. Suite 12,   Des Moines, IA 50311  




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