Camp Firefly Adult Registration
Saturday, Sept. 12 • Warriors’ Path State Park
Your name
*
First Name
Last Name
Camper name(s), if applicable
*
Relation to camper(s), if applicable
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Back
Next
Bereavement information
Name of the deceased
*
Relationship to the deceased
*
Age of the deceased
*
Date of death
*
Cause of death
*
Where did the death occur
*
Are you receiving professional support?
*
No
Yes, from social worker
Yes, from psychologist
Yes, from pastoral counselor
Yes, from family therapist
Was the deceased in hospice care?
*
yes
no
unknown
How did you learn about Camp Firefly?
*
Friend
Mailing
Radio
Newspaper
Community advertising
School counselor/teacher
Professional counselor
Other
Please identify any specific topic related to grief you would like to learn more about
*
Signature
*
Submit
Should be Empty: