Shannon’s Hope Camp Registration Building bridges of hope for lowcountry families since 1980 Please enable JavaScript in your browser to complete this form. - Step 1 of 5Have you already enrolled in Stepping Stones Program? *YesNo- Please Complete Enrollment Form before continuing Not Sure (see below)OtherUnsure ? If your child has already participated in one of our programs, please select YES and continue with this form. If you select NO, and your child has not participated, please complete the following enrollment before continuing to register. Your Name *FirstLastEmail *Shannon's Hope Camper RegistrationNextChild's Name *FirstLastBirthdate *Shirt Size *Youth SmallYouth MediumYouth LargeYouth XLAdult SmallAdult MediumAdult LargeAdult XLAdult XXLHobbies or InterestsHas there been any other significant deaths since the child/teen was enrolled in Stepping Stones?YesNoProvide details on new deathIs there anything new that you feel is important for us to know about the child/teen?PreviousNextEmergency Contact InformationIn the event a emergency occurs, we will contact the parent or legal guardian. We ask you provide us with two OTHER contacts, in the event we are unable to reach you.Emergency Contact #1 Cell NumberEmergency Contact #1 Name & Relationship to Child?Emergency Contact #2 Cell NumberEmergency Contact #2 Name & Relationship to Child?Medical InformationDoes the child have any medical conditions that we should be aware of?NoYesOtherPlease explain:May the child take Tylenol or Advil if needed?YesNoOtherDoes this child take any medications? YesNoALL medications will be turned into the Camp Nurse upon registration & they will be dispensed by the Camp Nurse ONLY. Medications MUST be in their original prescription bottle.Medication #1 NameMedication #1 DosageMedication #1 InstructionsMedication #2 Name Medication #2 Dosage Medication #2 Instructions Medication #2 Reason for MedicationMedication #3 Name Medication #3 Dosage Medication #3 Instructions Medication #3 Reason for Medication Medication #4 Name Medication #4 Dosage Medication #4 InstructionsMedication #4 Reason for Medication Medication #5 Name Medication #5 Dosage Medication #5 InstructionsMedication #5 Reason for MedicationList any additional medication here.Does the Child have any special diet restrictions? YesNoSpecial Diet (list foods and reasons)Does the Child have any allergies? YesNoAllergies & Reaction InformationDoes the Child have physical activity restrictions? YesNoPhysical Activities Restrictions (e.g. running)Is the child under care of a counselor, therapist, or any other mental health professional?YesNoPrefer Not to SayName of mental health providerContact Information of mental health provider With prior notice, do we have permission to coordinate services with the above mentioned provider?YesNoMaybePreviousNextTransportationDoes your child need transportation ? NoYesMaybeChoose one of the following: Yes, both to and from camp from North CharlestonOnly to camp from North CharlestonOnly from Camp to North CharlestonI consent for my child to ride in a bus provided by Coastal Bus Line to and from Shannon's Hope CampI agreeCheckboxesFirst ChoiceSecond ChoiceThird ChoiceCOVID 19 WaiverI HAVE CAREFULLY READ AND FULLY UNDERSTAND ALL PROVISIONS OF THIS RELEASE, AND FREELY AND KNOWINGLY ASSUME THE RISK AND WAIVE MY RIGHTS CONCERNING LIABILITY AS DESCRIBED ABOVE. The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is reported to be extremely contagious. The state of medical knowledge is evolving, but the virus is believed to spread from person to person contact and/or by contact with contaminated surfaces and objects, and even possibly in the air. People reportedly can be infected and show no symptoms and therefore unknowingly spread the disease. The exact methods of spread and contraction are unknown, and there is no known treatment, cure or vaccine for COVID-19. Evidence has shown that COVID-19 can cause serious potentially life-threatening illness and even death. Bridges/Shannon's Hope Camp cannot prevent you or your child(ren) from becoming exposed to, contracting or spreading COVID-19 while participating , being on premises, or in transportation methods provided by collaborative organizations. It is not possible to prevent against the presence of the disease. Therefore, if you choose to utilize Bridges services, and/or enter onto its premises you may be exposing yourself to and/or increasing your risk of contracting or spreading COVID-19. ASSUMPTION OF RISK: I have read and understood the above warning concerning COVID-19. I hereby choose to accept the risk of contracting COVID-19 for myself and/or my child(ren) in order to utilize Bridges services and enter premises. These services are of such value to me and/or my child(ren) that I accept the risk of being exposed to, contracting, and/or spreading COVID-19 in order to utilize Bridges’s services and premises in person. WAIVER OF LAWSUIT/LIABILITY: I hereby forever release and waive my right to bring suit against Bridges its agents and employees, volunteers, board members , and other representatives /collaborating organizations in connection with exposure, infection and/or spread of COVID-19 related to utilizing Bridges services and premises. I understand that this waiver means I give up my right to bring any claims including for personal injuries, death, disease or property losses, or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages whether known or unknown, foreseen or unforeseen. Policies & Consent for Participation Please read over the information below and sign your name electronically if you give consent I, the undersigned parent (or guardian) of the child named above (hereinafter referred to as “child”), give my consent for the child’s participation in Bridges programming. EMERGENCY CARE RELEASE: I authorize, that in an emergency situation, Bridges personnel/school staff to call emergency services. In the event that I cannot be reached or be present, I hearby authorize Bridges personnel/school staff to execute any and all documents including any necessary releases in my behalf which might be required by any medical facility to perform any emergency care on account of an accident or illness sustained or incurred by the child while participating in Bridges’ programming. I further agree that in consideration of my child participation in Bridges’ programming, I will hold Bridges for End-of-Life personnel/school staff harmless from any action by me, my child, or family members on account of any injury or damage sustained or suffered by my child while attending Bridges’ programming, and hereby waive any right of legal action against Bridges for End-of-Life. MANDATORY REPORTING: Bridges’ staff and volunteers will maintain all confidentiality when working with children. However, South Carolina law does require that any of us report suspected cases of abuse or neglect to ensure the safety of our community’s children. A report must happen if a volunteer or staff member has any reason to believe that a child’s physical or mental health has been, or may be, adversely affected by abuse or neglect. By signing below, you acknowledge you have read and agree to all items listed above. SignatureClear SignaturePreviousNextCamp Pre-EvaluationChild/Teen speaks openly about their feelings and emotions *NeverSometimesAlwaysNot SureChild/Teen displays unhealthy coping skills *NeverSometimesAlwaysNot SureChild/Teen reaches out to people when they need to talk *NeverSometimesAlwaysNot SureChild/Teen shares stories/memories of the deceased *NeverSometimesAlwaysNot SureChild/Teen asks questions about the death or deceased *NeverSometimesAlwaysNot SureChild/Teen makes goals for the future *NeverSometimesAlwaysNot SureNotes or any additional explanation or observancesSubmit Get Started Enroll Complete the Stepping Stones Membership Form Schedule Schedule time with our staff to discuss your needs & our support l Register Sign-up to attend one of our activities or events
