Camp Healing Hearts

By signing below, I consent to participation with the above indicated child(ren) in bereavement camp. I agree to seek assistance from Hands Holding Hearts or other community support, should I or my child(ren) need further assistance. We agree to maintain confidentiality of others in the group.

I understand that at the end of camp I and my children will be required to complete a camp evaluation form which is to be completed and returned to Hands Holding Hearts.

I hereby give permission for my child(ren) to attend Camp Healing Hearts. I understand that the camp’s goal is to help facilitate the bereavement process for my family and provide support for us in expressing our grief.

A screening interview is required for each child participating. Campers are accepted on a first come, first serve basis after it is determined they are emotionally ready to engage in camp. Priority is given to those who have not yet attended one of our camps.

I hereby consent to participation with the above indicated child(ren) in the Bereavement Camp. I agree to seek assistance from Camp Healing Hearts staff or other community support, should I or my child(ren) need further assistance. We agree to maintain confidentiality of others in the group. Exceptions to this policy would include reports of child abuse, possibility of harm to child or others, and court ordered records. I will allow for information provided in the application to be shared with camp counselors who will be working with the children.

I acknowledge that it is the responsibility of the parent or guardian to ensure that children are picked up from camp on time, or a late fee of $20 per half hour will be imposed, and that staff are unable to remain at the camp if a long delay occurs.

I give permission to Camp Healing Hearts to photograph and/or videotape myself and/or my child during our activities. I understand that these videos and photos are the property of Hands Holding Hearts and may be used for educational/promotional purposes now and/or in the future. Examples include a photo in the local paper or given to group participants as keepsakes. If the artwork is used as a case study it will be presented maintaining confidentiality.

I authorize Hands Holding Hearts volunteers and staff to order any first aid/medical treatment deemed necessary to the above named child in case of injury or illness, and agree to indemnify and hold Hands Holding Hearts harmless from any claims of injury which could be sustained by the said child(ren) or adults during Hands Holding Hearts activities. I will not send my child to activities if they are ill.

In consideration of the above named child(ren) being granted permission to attend Camp Healing Hearts I, for myself and on behalf of my child(ren), release and discharge Hands Holding Hearts, their agents, employees, volunteers, and officers from any and all claims, demands, actions, and judgments which I or my child(ren) ever had, now have, or may have against Hands Holding Hearts for personal injuries, either physical or emotional, known or unknown, and injury to property, real or personal, sustained by me or my child(ren)’s person or property during our attendance at Camp Healing Hearts, whether the injury is caused by negligence or any other fault.

Also, in consideration of the above-named child(ren) being granted my permission to attend Camp Feeling Better, I agree to indemnify and hold harmless Hands Holding Hearts for any claims, demands, actions, and judgments whatsoever of every name and nature, both in law and equity, which I or my child(ren) ever had, now have, or may have against Hands Holding Hearts for personal injuries, either physical or emotional, known or unknown, and injury to property, real or personal, sustained by me or my child(ren)’s person or property during our attendance at Camp Healing Hearts, due to injury caused by or arising from negligence.

I give permission for my participating child(ren) to leave the site of the camp to engage in a nature walk accompanied by camp staff members, weather permitting.

If my child(ren) sustains an injury or manifests an illness at the camp that requires medical attention or treatment on an emergency basis, I request that Hands Holding Hearts contact the adults listed below immediately. In the event of a medical emergency, if Hands Holding Hearts cannot reach any of the emergency contacts listed below, I authorize Hands Holding Hearts staff to obtain necessary emergency first aid / medical treatment for the above named child(ren).

I will not send my child(ren) to Hands Holding Hearts activities if I know that they are ill.

Parents and guardians: please read this together with your child(ren) and agree before the first day of camp.

1. The STOP Rule: If an adult or other camper says “Please stop,” I agree to stop what I am doing immediately.

2. The Buddy Rule: I will always be sure that a buddy or a counselor is with me or knows where I am at all times. I understand that I need to stay with the group when we are doing scheduled activities.

3. The Group Member Rule: I understand I need to respect my group members and counselors when they are sharing. I will wait until that person is done speaking to talk.

4. The Respect Rule: I promise I will not intentionally hurt anyone or make them feel uncomfortable with my words (put downs, teasing, name calling) or my actions (hitting, shoving).

5. The Pass Rule: I understand that if I do not want to participate in an activity or discussion I can pass; however, I must stay with my group.

Consequences. Step 1: If I am having a hard time, I can ask a counselor for help to follow the rules or for support. Step 2: If I cannot follow the rules after help from a counselor, I will be removed from the group to meet with a counselor individually, and my guardian will be called. Step 3: If I continue to be unable to follow the rules, my parent or guardian will be called to pick me up, and we will discuss whether I am able to return to Camp Feeling Better. I agree that these rules are for my safety and the safety of others, and I will follow them to the best of my ability.

As a group member, I have rights and benefits as well as duties, and I understand that some of them are described here in this agreement.

This group will meet each month or as determined by the group and therapist while in session.

The cost to me of the group sessions is variable according to the topic of each session. I agree to pay the full fee if I do not show up for group without providing 24 hour advance notice of my absence, except in case of emergency or illness. Payment is due in full at the start of a grief support series; for open groups, the fee will be billed after each session.

I may contact my health provider to determine if I have group therapy coverage for out of network services. If so, I will notify the therapist what information needs to be provided to qualify for this coverage, and the therapist will provide an invoice to me with diagnostic codes and relevant information for reimbursement that I may submit to my insurance provider.

The purpose of this group is to provide me with an opportunity to achieve the following: to have my feelings validated by therapist and group members; to improve self-awareness of feelings and learn effective coping strategies to deal more effectively with areas of struggle; and to gain a safe and confidential sense of community and support through group.

I agree to work in this group by openly talking about my thoughts and feelings, honestly reporting my behaviors, and exchanging helpful feedback with group members.

I will use my best efforts to attend all meetings of this group for the full 60 or 90 minute group session (unless a conflict is discussed with group and therapist) even if I do not always feel like attending. If I know in advance that I cannot attend a session, I will inform the group and the therapist at least one week in advance. If I am prevented from attending due to illness or emergency, I will make reasonable attempts to notify the therapist by telephone as far in advance as possible before the scheduled group session.

I understand that by law, the therapist must report any suspected child abuse, elder abuse, or serious threats to harm myself or others, to the proper authorities.

I understand that confidentiality is not a choice but a right for every member in the group and my personal information will never be shared with anyone by the therapist. I understand and acknowledge that I also have a duty to not share or disclose other group members’ personal information, including their names and situations, to anyone outside of the group.

If I break confidentiality as described above, I understand that I will be asked to leave the group permanently, and I realize that I may face a possible lawsuit in which I have to pay damages to any person whose information was not kept confidential.

I understand that the therapist will keep a clinical case record of the content of the group sessions that will be kept in a locked confidential place, and this information can never be shared with anyone without expressed written consent from all members identified in the documentation.

Consent for Group Therapy Services: I have read and understood the contents of this agreement. My questions about this agreement have been answered. I agree to the professional and financial terms described in this agreement as indicated by my signature below.