First Name: Last Name: Email: Day Phone: Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Number of Attendees: Emergency Contact Name (someone not attending): Emergency Contact Phone Number: gender Birth Date: / / T-shirt size Name of Deceased: Date of death Cause of Death: Age at the time of death: Did anyone attending camp witness the death? Any other information you would like us to know? (Concerns, health issues, diagnoses, etc) How did you hear about us? I authorize Healing Hearts Connection and its agents and all persons acting under its authority to promote Hearts of Hope Family Grief Camp and Healing Hearts Connection, to use written statements, and recordings of me or my family. I waive any right to inspect or approve the finished product or the advertising or other copy, which may be used in connection or the use to which it may be applied. I release and discharge Healing Hearts Connection its agents and all persons acting under its authority, from any liability for any violation of any personal or property rights which I might have in connection with such materials. We offer aromatherapy options for children in our Camping Program (school age). All oils used are indicated for use in children over 2, and use is completely optional. I authorize my child(children) to grant approval of aromatherapy options. (If you wish to approve certain children only, please list them in the "Anything else we need to know" section.