Hope Camp Family Application

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What does your family hope to gain from camp?
Camper’s Previous Care: Have any of your campers ever lived outside of your home?
Camper Name:
Type of Care (i.e., foster care, orphanage, group home, residential treatment center)
Age at Entry
Duration of Stay
CPC 1. Camper Name:
CPC 1. Type of Care
CPC 1. Age at Entry
CPC 1. Duration of Stay
CPC 2. Camper Name:
CPC 2. Type of Care
CPC 2. Age at Entry
CPC 2. Duration of Stay
CPC 3. Camper Name:
CPC 3. Type of Care
CPC 3. Age at Entry
CPC 3. Duration of Stay
CPC 4. Camper Name:
CPC 4. Type of Care
CPC 4. Age at Entry
CPC 4. Duration of Stay
CPC 5. Camper Name:
CPC 5. Type of Care
CPC 5. Age at Entry
CPC 5. Duration of Stay
Have any of your campers experienced the following:
Yes
Explain
Name of Camper
A difficult Pregnancy
A difficult Pregnancy-- Yes
A difficult Pregnancy-- Explain
A difficult Pregnancy--Name of Camper
A difficult Birth
A difficult Birth--Yes
A difficult Birth--Explain
A difficult Birth--Name of Camper
Early Hospitalizations
Early Hospitalizations--Yes
Early Hospitalizations--Explain
Early Hospitalizations--Name of Camper
Neglect
Neglect--Yes
Neglect--Explain
Neglect--Name of Camper
Physical Abuse
Physical Abuse--Yes
Physical Abuse--Explain
Physical Abuse--Name of Camper
Sexual Abuse
Sexual Abuse--Yes
Sexual Abuse--Explain
Sexual Abuse--Name of Camper
Loss of Primary Caregiver
Loss of Primary Caregiver--Yes
Loss of Primary Caregiver--Explain
Loss of Primary Caregiver--Name of Camper
Other trauma
Other trauma--Yes
Other trauma--Explain
Other trauma--Name of Camper

Serious Illness/Injuries:
Camper’s Name
Illness/Injury
Date of Onset
Duration of Stay
Comments
Illness/Injury 1
Illness/Injury 1 --- Camper’s Name
Illness/Injury 1 --- Illness/Injury
Illness/Injury 1 --- Date of Onset
Illness/Injury 1 --- Duration of Stay
Illness/Injury 1 ---Comments
Illness/Injury 2
Illness/Injury 2 --- Camper’s Name
Illness/Injury 2 --- Illness/Injury
Illness/Injury 2 --- Date of Onset
Illness/Injury 3 --- Duration of Stay
Illness/Injury 2 --- Comments
Illness/Injury 3
Illness/Injury 3 --- Camper’s Name
Illness/Injury 3 --- Illness/Injury
Illness/Injury 3 --- Date of Onset
Illness/Injury 3 --- Duration of Stay
Illness/Injury 3 --- Comments
Illness/Injury 4
Illness/Injury 4 --- Camper’s Name
Illness/Injury 4 --- Illness/Injury
Illness/Injury 4 --- Date of Onset
Illness/Injury 4 --- Duration of Stay
Illness/Injury 4 --- Comments
Illness/Injury 5
Illness/Injury 5 --- Camper’s Name
Illness/Injury 5 --- Illness/Injury
Illness/Injury 5 --- Date of Onset
Illness/Injury 5 --- Duration of Stay
Illness/Injury 5 ---Comments
Illness/Injury 6
Illness/Injury 6 --- Camper’s Name
Illness/Injury 6 --- Illness/Injury
Illness/Injury 6 --- Date of Onset
Illness/Injury 6 --- Duration of Stay
Illness/Injury 6 ---Comments
Illness/Injury 7
Illness/Injury 7 --- Camper’s Name
Illness/Injury 7 --- Illness/Injury
Illness/Injury 7 --- Date of Onset
Illness/Injury 7 --- Duration of Stay
Illness/Injury 7 --- Comments
Camper Medical Diagnoses:
Most Recent
Camper’s Name
Diagnosis
Date of Diagnosis
Current Medications (if any)
Comments
Diagnosis 1
Diagnosis 1 Camper’s Name
Diagnosis 1 Diagnosis
Diagnosis 1 Date of Diagnosis
Diagnosis 1 Current Medications (if any)
Diagnosis 1 Comments
Diagnosis 2
Diagnosis 2 Camper’s Name
Diagnosis 2 Diagnosis
Diagnosis 2 Date of Diagnosis
Diagnosis 2 Current Medications (if any)
Diagnosis 3 Comments
Diagnosis 3
Diagnosis 3 Camper’s Name
Diagnosis 3 Diagnosis
Diagnosis 3 Date of Diagnosis
Diagnosis 3 Current Medications (if any)
Diagnosis 3 Comments
Diagnosis 4
Diagnosis 4 Camper’s Name
Diagnosis 4 Diagnosis
Diagnosis 4 Date of Diagnosis
Diagnosis 4 Current Medications (if any)
Diagnosis 4 Comments
Diagnosis 5
Diagnosis 5 Camper’s Name
Diagnosis 5 Diagnosis
Diagnosis 5 Date of Diagnosis
Diagnosis 5 Current Medications (if any)
Diagnosis 5 Comments
Allergies/Food Allergies/Food Restrictions:
Camper’s Name
Allergy
Comments
Camper’s Name 1 (Allergies)
Allergies 1 (Allergies)
Comments 1 (Allergies)
Camper’s Name 2 (Allergies)
Allergies 2 (Allergies)
Comments 2 (Allergies)
Camper’s Name 3 (Allergies)
Allergies 3 (Allergies)
Comments 3 (Allergies)
Camper’s Name 4 (Allergies)
Allergies 4 (Allergies)
Comments 4 (Allergies)
Camper’s Name 5 (Allergies)
Allergies 5 (Allergies)
Comments 5 (Allergies)
Physical Limitations:
Camper’s Name
Diagnosis
Date of Diagnosis
Current Medications (if any)
Comments
Physical 1 -- Camper’s Name
Physical 1 -- Diagnosis
Physical 1 --Date of Diagnosis
Physical 1 -- Current Medications (if any)
Physical 1 -- Comments
Physical 2 --Camper’s Name
Physical 2 -- Diagnosis
Physical 2 -- Date of Diagnosis
Physical 2 -- Current Medications (if any)
Physical 2 -- Comments
Physical 3 --Camper’s Name
Physical 3 --Diagnosis
Physical 3 -- Date of Diagnosis
Physical 3 --Current Medications (if any)
Physical 3 --Comments
Physical 4 --Camper’s Name
Physical 4 --Diagnosis
Physical 4 -- Date of Diagnosis
Physical 4 --Current Medications (if any)
Physical 4 --Comments
Physical 5 --Camper’s Name
Physical 5 --Diagnosis
Physical 5 -- Date of Diagnosis
Physical 5 --Current Medications (if any)
Physical 5 --Comments

Camper’s Psychological Diagnoses:
Camper Name
Diagnosis
Date of Diagnosis
Current Medications (if any)
Comments
Camper Name 1 (Psychological Diagnoses:)
Diagnosis 1 (Psychological Diagnoses:)
Date of Diagnosis 1 (Psychological Diagnoses:)
Current Medications 1 (Psychological Diagnoses:)
Comments 1 (Psychological Diagnoses:)
Camper Name 2 (Psychological Diagnoses:)
Diagnosis 2 (Psychological Diagnoses:)
Date of Diagnosis 2 (Psychological Diagnoses:)
Current Medications 2 (Psychological Diagnoses:)
Comments 2 (Psychological Diagnoses:)
Camper Name 3(Psychological Diagnoses:)
Diagnosis 3 (Psychological Diagnoses:)
Date of Diagnosis 3 (Psychological Diagnoses:)
Current Medications 3 (Psychological Diagnoses:)
Comments 3 (Psychological Diagnoses:)
Camper Name 4 (Psychological Diagnoses:)
Diagnosis 4 (Psychological Diagnoses:)
Date of Diagnosis 4 (Psychological Diagnoses:)
Current Medications 4 (Psychological Diagnoses:)
Comments 4 (Psychological Diagnoses:)
Camper Name 5 (Psychological Diagnoses:)
Diagnosis 5 (Psychological Diagnoses:)
Date of Diagnosis 5 (Psychological Diagnoses:)
Current Medications (if any) 5 (Psychological Diagnoses:)
Comments 5 (Psychological Diagnoses:)
Camper Name 6 (Psychological Diagnoses:)
Diagnosis 6 (Psychological Diagnoses:)
Date of Diagnosis 6 (Psychological Diagnoses:)
Current Medications (if any) 6 (Psychological Diagnoses:)
Comments 6 (Psychological Diagnoses:)
Camper Name 7 (Psychological Diagnoses:)
Diagnosis 7 (Psychological Diagnoses:)
Date of Diagnosis 7 (Psychological Diagnoses:)
Current Medications (if any) 7 (Psychological Diagnoses:)
Comments 7 (Psychological Diagnoses:)
Camper Name 8 (Psychological Diagnoses:)
Diagnosis 8 (Psychological Diagnoses:)
Date of Diagnosis 8 (Psychological Diagnoses:)
Current Medications (if any) 8 (Psychological Diagnoses:)
Comments 8 (Psychological Diagnoses:)
Camper’s Behavioral Concerns:
YES
Explain
Camper Name(s)
Do any children have behavioral difficulties?
Do any children have behavioral difficulties?.-- Yes
Do any children have behavioral difficulties?.-- Explain
Do any children have behavioral difficulties?.-- Camper Name(s)
Do any children have emotional difficulties?
Do any children have emotional difficulties? -- Yes
Do any children have emotional difficulties? --Explain
Do any children have emotional difficulties? -- Camper Name(s)
Do any children have educational difficulties?
Do any children have educational difficulties?-- Yes
Do any children have educational difficulties?-- Explain
Do any children have educational difficulties?--Camper Name(s)
Do any children have sensory difficulties?
Do any children have behavioral difficulties?-- Yes
Do any children have behavioral difficulties?--Explain
Do any children have behavioral difficulties?-- Camper Name(s)
Do any children have social difficulties?
Do any children have social difficulties?-- Yes
Do any children have social difficulties?-- Explain
Do any children have social difficulties?-- Camper Name(s)
Have you ever worried about the physical safety of any of your children or others around any of your children?
Have you ever worried about the physical safety of any of your children or others around any of your children?-- Yes
Have you ever worried about the physical safety of any of your children or others around any of your children?--Explain
Have you ever worried about the physical safety of any of your children or others around any of your children?--Camper Name(s)
Have any of your children ever harmed or attempted to harm another person, animal, or themselves?
Have any of your children ever harmed or attempted to harm another person, animal, or themselves? -- Yes
Have any of your children ever harmed or attempted to harm another person, animal, or themselves? --Explain
Have any of your children ever harmed or attempted to harm another person, animal, or themselves? --Camper Name(s
Do any of your children experience sensory issues such as sensitivies to light, sound, touch, textures, smells, etc.
Do any of your children experience sensory issues such as sensitivies to light, sound, touch, textures, smells, etc. -- Yes
Do any of your children experience sensory issues such as sensitivies to light, sound, touch, textures, smells, etc. --Explain
Do any of your children experience sensory issues such as sensitivies to light, sound, touch, textures, smells, etc. -- Camper Name(s
Do any of your children have social difficulties with peers, authority figures, males vs females?
Do any of your children have social difficulties with peers, authority figures, males vs females? --Yes
Do any of your children have social difficulties with peers, authority figures, males vs females? --Explain
Do any of your children have social difficulties with peers, authority figures, males vs females? --Camper Name(s

Camper’s Behavioral or Emotional Problems resulting in a hospitalization:
Most Recent
Camper Name
Reason
Date of Entry
Duration of Stay
Comments
Hospitalization 1
Hospitalization 1 -- Camper Name
Hospitalization 1 -- Reason
Hospitalization 1 -- Date of Entry
Hospitalization 1 -- Duration of Stay
Hospitalization 1 -- Comments
Hospitalization 2
Hospitalization 2 -- Camper Name
Hospitalization 2 -- Reason
Hospitalization 2 -- Date of Entry
Hospitalization 2 -- Duration of Stay
Hospitalization 2 -- Comments
Hospitalization 3
Hospitalization 3 -- Camper Name
Hospitalization 3 -- Reason
Hospitalization 3 -- Date of Entry
Hospitalization 3 --Duration of Stay
Hospitalization 3 -- Comments
Hospitalization 4
Hospitalization 4 -- Camper Name
Hospitalization 4 -- Reason
Hospitalization 4 -- Date of Entry
Hospitalization 4 -- Duration of Stay
Hospitalization 4 -- Comments
Hospitalization 5
Hospitalization 5-- Camper Name
Hospitalization 5-- Reason
Hospitalization 5-- Date of Entry
Hospitalization 5-- Duration of Stay
Hospitalization 5-- Comments
Hospitalization 6
Hospitalization 6 -- Camper Name
Hospitalization 6 -- Reason
Hospitalization 6 -- Date of Entry
Hospitalization 6 -- Duration of Stay
Hospitalization 6 -- Comments
Camper Specific Information:
Camper’s Name
Three Major Strengths
Three Major Challenges
Three Goals for Camp
Camper’s Name 1
Three Major Strengths 1
Three Major Challenges 1
Three Goals for Camp 1
Camper’s Name 2
Three Major Strengths 2
Three Major Challenges 2
Three Goals for Camp 2
Camper’s Name 3
Three Major Strengths 3
Three Major Challenges 3
Three Goals for Camp 3
Camper’s Name 4
Three Major Strengths 4
Three Major Challenges 4
Three Goals for Camp 4

Camper’s Parent/Caregiver Information:
Family’s major strengths:
Family’s major strengths:
Family’s major challenges:
Parent(s) Major challenges
Parent(s) Three goals during camp:
Family’s major strengths:
Family’s major challenges:
Parent(s) Major Strengths
Parent(s) Major challenges
Parent(s) Three goals during camp:
I acknowledge I have completed this application to the best of my ability
Caregiver/Parent Signature 1
Date
Caregiver/Parent Signature
Date
Caregiver/Parent Signature 2
Date
Caregiver/Parent Signature
Date
Caregiver/Parent Signature 3
Date
Caregiver/Parent Signature
Date

By hitting submit, you understand that Counseling Connections for Change, Inc. has your permission to use yours or your child’s photograph publicly to promote the Hope Camp in the future. You understand that images may be used in print publications, online publications, presentations, websites, and social media. You also understand that no royalty fee or other compensation shall become payable to you by reason of such use.