Hope Hospice

Children Attending Camp

Please provide information for each child who will be attending Camp HavenHeart.

Full attendance is required. Campers are accepted on a first-come, first-serve basis after a screening interview confirms they are emotionally ready to participate. Priority is given to those who have not yet attended one of our camps. Space is limited.

Parents / Guardians & Contact

Contact information for the parent or legal guardian registering.

Mailing Address

Street Address *

City *

State & Zip *

Within New Braunfels city limits?

County of Residence *

Phone Numbers

Home

Work

Cell *

Custody

Are you the legal guardian of the above-named child(ren)? *

Yes No

Has there been a divorce or custody agreement involving the child(ren)? *

Yes No

A copy of the divorce decree and relevant custody paperwork will be required.

Emergency Contact

Please list someone other than a parent/guardian to contact in case of emergency.

Name *

Relationship to child

Phone Number *

T-Shirt Sizes * (required for at least one person)

List each family member attending and select their size.

How did you hear about Camp HavenHeart?

What do you hope your child gains from the camp experience?

Information Related to the Death

This information helps our counselors prepare to support your family. All information is confidential.

About the Person Who Died

Name of person who died *

Date of death *

Age at time of death

Date of birth (if known)

Relationship to family members *

Was the deceased served by Hope Hospice?

Yes No

Circumstances of the Death

Cause of death

Nature of death

Sudden Lingering Traumatic

Where did the person die?

Did the deceased live with your family?

Yes No

Was anyone in the family present when the death occurred? If so, who?

Children's Understanding & End-of-Life Traditions

What have the children been told about the death?

What end-of-life traditions were practiced? (e.g., wake, funeral, burial, cremation)

Did the children attend?

Yes No

Family beliefs / religious affiliation

Other Context

Any other information about the death you'd like us to know?

Any additional information to help us work with your family (special needs, medical concerns, personality traits, etc.)

Major changes since the death (divorce, moves, school changes, health problems, financial hardship, loss of pet, etc.)

Traumatic events prior to the death (other deaths, divorce, history of abuse, etc.)

Are any family members seeing a counselor? If yes, name(s):

Are any family members taking medication? (List person, medication, and purpose)

Family Communication Style about the Death

How Family Members Are Coping

List each family member attending camp in the columns below and check all that apply.

Enter family member names in the header row, then check behaviors that apply to each person. This helps our counselors understand each individual's needs before camp begins.

Enter names of family members attending camp (up to 6):

Behavior / Indicator	Member 1	Member 2	Member 3	Member 4	Member 5	Member 6
Able to talk about the person who died
Refusing to talk about the deceased
Avoiding any reminders of the deceased
Expressing suicidal feelings & ideation
Engaging in self-harm behavior
Reaching out to others for support and comfort
Isolating from others / withdrawal from activities
Acknowledging and expressing grief-related feelings as they arise
Increased aggression towards self or others
Separation anxiety
Changes in behavior (sleeping, eating, etc.)
Conflict in relationships with friends or family

Other (please describe)

Bereavement Data Form

This data is required by local, state, and federal guidelines to qualify for funding. All personal information is kept strictly confidential and used for statistical purposes only.

Ethnic Origin

Please list all family members attending camp alongside their ethnic origin.

Household & Income

Number of people residing in household (all adults & children) *

Total combined family income last year *

Cause of death of loved one

Consent, Communications & Signatures

Please read each section carefully and sign below.

Email Consent

Email consent *

Yes, I consent No

Email address

Telephone & Voicemail Consent

Voicemail consent *

Yes, I consent No

Photo & Video Permission

Photo / video permission *

Yes No

Confidentiality Statement

I have read and understand the confidentiality policies *

I understand and agree

Informed Consent, Release & Indemnification

Signatures

By typing your name below, you are providing your electronic signature and agree to all terms above.

Signature of Parent or Legal Guardian #1

Full name (electronic signature) *

Date *

Signature of Parent or Legal Guardian #2 (if applicable)

Full name (electronic signature)

Date

After submitting: All families will be contacted by May 25, 2026. If you sent in a registration form and have not heard from us by then, please call the Grief Center at 830-358-5300.

Camp HavenHeart Summer 2026

Children Attending Camp

Parents / Guardians & Contact

Information Related to the Death

How Family Members Are Coping

Bereavement Data Form

Consent, Communications & Signatures

Registration Submitted

Children Attending Camp

Parents / Guardians & Contact

Information Related to the Death

How Family Members Are Coping

Bereavement Data Form

Consent, Communications & Signatures

Our Commitment to You

Registration Submitted