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Page 1

Thank you for your interest in Camp Erin® Online. Eluna is honored to provide you care and support!   For information on current Camp Erin Online programs, visit www.elunanetwork.org/camp-erin-online/.   

For family programs, the application should be completed by the legal guardian of the participating youth.
The application will take approximately 15-20 minutes to complete.
To complete the report in multiple sittings, click the “Save my progress and resume later” checkbox at the top of the page and follow the instructions.
Submission of this application does not constitute acceptance into Camp Erin Online programs. After completion of the application, a member of our Camp Erin Online team will contact you to communicate next steps in the registration process. 
For information about how we collect, use, share and otherwise process information about you, please see our Privacy Policy.

With questions, please email KellyPetersohn@elunanetwork.org. 

IMPORTANT: Camp Erin Online operates independently from our in-person Camp Erin programs. Camp Erin Online requires a separate application.

Is your family currently part of the Camp Erin Online community?

Yes, I have previously completed a Camp Erin Online application. No, I have not completed a Camp Erin Online application.

Please confirm ALL Camp Erin programs you or your youth/family have attended:

In-person - hosted by a local grief support program. Online - hosted by Eluna.

This adult will be the point of contact for all Camp Erin Online Programming communication.

Primary Adult First Name:

Primary Adult Last Name:

Primary Adult Email:

Camp Erin Online Program Registration

Camp Erin Online programs

We are currently accepting applications for the following programs. For more program information, visit Camp Erin Online Programs. Please indicate the program(s) for which you would like to register:

Grief Compass Group provides support to families finding their way through grief. Camp Erin Online invites you to come and experience community with other families who are grieving. This group meets on the 2nd and 4th Thursday of each month.

Note: Prior to attending, families will attend an Introduction/Interest Meeting. Dates and times will be shared by email following completion of application.

Number of individuals attending Grief Compass Group:

First Name:

Last Name:

Participant Type:

First Name:

Last Name:

Participant Type:

First Name:

Last Name:

Participant Type:

First Name:

Last Name:

Participant Type:

First Name:

Last Name:

Participant Type:

First Name:

Last Name:

Participant Type:

First Name:

Last Name:

Participant Type:

First Name:

Last Name:

Participant Type:

First Name:

Last Name:

Participant Type:

First Name:

Last Name:

Participant Type:

First Name:

Last Name:

Participant Type:

First Name:

Last Name:

Participant Type:

T-shirt size

T-shirt self description

Favorite Color

First Name:

Last Name:

Participant Type:

T-shirt size

T-shirt self description

Favorite Color

First Name:

Last Name:

Participant Type:

T-shirt size

T-shirt self description

Favorite Color

First Name:

Last Name:

Participant Type:

T-shirt size

T-shirt self description

Favorite Color

First Name:

Last Name:

Participant Type:

T-shirt size

T-shirt self description

Favorite Color

First Name:

Last Name:

Participant Type:

T-shirt size

T-shirt self description

Favorite Color

First Name:

Last Name:

Participant Type:

T-shirt size

T-shirt self description

Favorite Color

First Name:

Last Name:

Participant Type:

T-shirt size

T-shirt self description

Favorite Color

First Name:

Last Name:

Participant Type:

T-shirt size

T-shirt self description

Favorite Color

First Name:

Last Name:

Participant Type:

T-shirt size

T-shirt self description

Favorite Color

First Name:

Last Name:

Participant Type:

T-shirt size

T-shirt self description

Favorite Color

I would like to speak to a Camp Erin Online team member to learn more.

Please share the address you would like program supplies to be mailed to:

Address:

City:

State:

Zip Code:

Any additional registration information:

Note: Please ensure that each individual listed is captured in the following application questions.

Application Updates

Have there been any additional losses since completing your Camp Erin Online application?

Yes

Number of Additional Losses (If you are remembering more than 3 additional people, please contact KellyPetersohn@elunanetwork.org.)

Deceased Individual 1 Information

Name of Person who died

Was the deceased an active, reserve, national guard member or retired veteran?

Yes

Unknown

Please select military affiliation:

Cause of Death:

Please list cause of death:

Date of Death:

MM/DD/YYYY format, please estimate as close as possible.

Age at time of death:

Was this person a significant caregiver of the youth participating in Camp Erin Online? This could be a family or nonfamily member who provided significant support (housing, financial, care, etc.) to the youth.

Yes

How would you describe your family's communication style about this death?

Open communicationRarely talk about the deathAvoid talking about the deathRefuse to talk about the deathPrefer to self-describe

Communication self-description

Deceased Individual 2 Information

Name of Person who died

Was the deceased an active, reserve, national guard member or retired veteran?

Yes

Unknown

Please select military affiliation:

Cause of Death:

Please list cause of death:

Date of Death:

MM/DD/YYYY format, please estimate as close as possible.

Age at time of death:

Yes

How would you describe your family's communication style about this death?

Open communicationRarely talk about the deathAvoid talking about the deathRefuse to talk about the deathPrefer to self-describe

Communication self-description

Deceased Individual 3 Information

Name of Person who died

Was the deceased an active, reserve, national guard member or retired veteran?

Yes

Unknown

Please select military affiliation:

Cause of Death:

Please list cause of death:

Date of Death:

MM/DD/YYYY format, please estimate as close as possible.

Age at time of death:

Yes

How would you describe your family's communication style about this death?

Open communicationRarely talk about the deathAvoid talking about the deathRefuse to talk about the deathPrefer to self-describe

Communication self-description

Are there any additional participating family members that need to be added to your application?

Yes

Number of additional youth (If you are adding more than 3 youth, please contact KellyPetersohn@elunanetwork.org)

Youth 1 Information

First Name:

Last Name:

What name would this youth like to be called? Does not need to be legal name:

Date of Birth:

Current grade level (if summer, grade completed):

Grade level other:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Share self-description here:

Does youth qualify for free lunch at school?

Yes

The youth is remembering their:

Mother	Father	Sibling	Grandmother
Grandfather	Stepmother	Stepfather	Aunt
Uncle	Cousin	Friend	Relationship not listed

Relationship description:

What did this youth call the person who died (i.e. Mommy, Daddy, Papa):

Did this youth attend an end of life/celebration/service?

Yes

No Service Occured

Prefer to self-describe

End of life/celebration/service self-description:

Does the youth know the facts about the cause of death?

Yes

Unsure

Prefer to self-describe

Cause of death self-description:

Current or past support (check all that apply)

Has attended an in-person Camp Erin.	Has never received grief, mental health, or behavioral health support.
Currently receiving grief support (i.e., grief center/program/grief counselor).	Currently receiving mental health or behavioral health support (i.e., traditional outpatient therapist).
Has received grief support in the past.	Has received mental health or behavioral health support in the past.
Prefer to self-describe.

Support counseling details:

Does youth have any physical, cognitive, social or mental health considerations that would be helpful for us to know as we support your family?

Please share important details:

Has this youth experienced abuse of any kind? Any details provided will be used to accommodate safety needs of this youth.

Please share any related details:

Special interests/hobbies/personality traits/favorite color:

Any additional information to share:

Youth 2 Information

First Name:

Last Name:

What name would this youth like to be called? Does not need to be legal name:

Date of Birth:

Current grade level (if summer, grade completed):

Grade level other:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Does youth qualify for free lunch at school?

Yes

The youth is remembering their:

Mother	Father	Sibling	Grandmother
Grandfather	Stepmother	Stepfather	Aunt
Uncle	Cousin	Friend	Relationship not listed

Relationship description:

What did this youth call the person who died (i.e. Mommy, Daddy, Papa):

Did this youth attend an end of life/celebration/service?

Yes

No service occured

Prefer to self-describe

End of life/celebration/service self-description:

Does the youth know the facts about the cause of death?

Yes

Unsure

Prefer to self-describe

Cause of death self-description:

Current or past support (check all that apply)

Has attended an in-person Camp Erin.	Has never received grief, mental health, or behavioral health support.
Currently receiving grief support (i.e., grief center/program/grief counselor).	Currently receiving mental health or behavioral health support (i.e., traditional outpatient therapist).
Has received grief support in the past.	Has received mental health or behavioral health support in the past.
Prefer to self-describe.

Support counseling details:

Does youth have any physical, cognitive, social or mental health considerations that would be helpful for us to know as we support your family?

Please share important details:

Has this youth experienced abuse of any kind? Any details provided will be used to accommodate safety needs of this youth.

Please share any related details:

Special interests/hobbies/personality traits/favorite color:

Any additional information to share:

Youth 3 Information

First Name:

Last Name:

What name would this youth like to be called? Does not need to be legal name:

Date of Birth:

Current grade level (if summer, grade completed):

Grade level other:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Does youth qualify for free lunch at school?

Yes

The youth is remembering their:

Mother	Father	Sibling	Grandmother
Grandfather	Stepmother	Stepfather	Aunt
Uncle	Cousin	Friend	Relationship not listed

Relationship description:

What did this youth call the person who died (i.e. Mommy, Daddy, Papa):

Did this youth attend an end of life/celebration/service?

Yes

No service occurred

Prefer to self-describe

End of life/celebration/service self-description?

Does the youth know the facts about the cause of death?

Yes

Unsure

Prefer to self-describe

Cause of death self-description?

Current or past support (check all that apply)

Has attended an in-person Camp Erin.	Has never received grief, mental health, or behavioral health support.
Currently receiving grief support (i.e., grief center/program/grief counselor).	Currently receiving mental health or behavioral health support (i.e., traditional outpatient therapist).
Has received grief support in the past.	Has received mental health or behavioral health support in the past.
Prefer to self-describe.

Support counseling details:

Does youth have any physical, cognitive, social or mental health considerations that would be helpful for us to know as we support your family?

Please share important details:

Has this youth experienced abuse of any kind? Any details provided will be used to accommodate safety needs of this youth.

Please share any related details:

Special interests/hobbies/personality traits/favorite color:

Any additional information to share:

Number of additional adults (If you are adding more than 3 adults, please contact KellyPetersohn@elunanetwork.org)

Adult 1 Information

First Name:

Last Name:

Preferred name:

Date of Birth:

MM/DD/YYYY

Email:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Relationship to youth:

Please list your relationship here:

Is this adult the primary caregiver of the youth?

Yes

Is this adult the legal guardian of the youth?

Yes

Who is this person remembering? If remembering more than one person, please check all appropriate boxes. The adult is remembering THEIR:

Spouse/Partner	Child's Parent	Mother	Father
Sibling	Grandmother	Grandfather	Stepmother
Stepfather	Aunt	Uncle	Cousin
Friend	Relationship not listed

Relationship description:

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Military status: Is this person an active, reserve, national guard member or veteran? ?

Yes

Please select military affiliation:

Adult 2 Information

First Name:

Last Name:

Preferred name:

Date of Birth:

MM/DD/YYYY

Email:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Relationship to youth:

Please list your relationship here:

Is this adult the primary caregiver of the youth?

Yes

Is this adult the legal guardian of the youth?

Yes

Who is this person remembering? If remembering more than one person, please check all appropriate boxes. The adult is remembering THEIR:

Spouse/Partner	Child's Parent	Mother	Father
Sibling	Grandmother	Grandfather	Stepmother
Stepfather	Aunt	Uncle	Cousin
Friend	Relationship not listed

Relationship description:

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Military status: Is this person an active, reserve, national guard member or veteran?  ?

Yes

Please select military affiliation:

Adult 3 Information

First Name:

Last Name:

Preferred name:

Date of Birth:

MM/DD/YYYY

Email:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Relationship to youth:

Please list your relationship here:

Is this adult the primary caregiver of the youth?

Yes

Is this adult the legal guardian of the youth?

Yes

Who is this person remembering? If remembering more than one person, please check all appropriate boxes. The adult is remembering THEIR:

Spouse/Partner	Child's Parent	Mother	Father
Sibling	Grandmother	Grandfather	Stepmother
Stepfather	Aunt	Uncle	Cousin
Friend	Relationship not listed

Relationship description:

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Military status: Is this person an active, reserve, national guard member or veteran? ?

Yes

Please select military affiliation:

Have the needs of you/your family changed since completing your Camp Erin Online application?

Yes

Please share related information here.

Any additional information to note:

Page 3 of 8 - Primary Adult Information

I am (check all that apply):

An adult guardian participating with my youth

A young adult participating in programming

What would you like to be called? This does not need to be legal name:

Pronouns:

Share self-description here:

Gender:

Gender self-description

Date of Birth

MM/DD/YYYY

Phone Number:

Street Address:

City:

State/Province

Zip Code/ Postal Code:

Time Zone:

Relationship to youth:

Please list your relationship here:

Is this adult the primary caregiver of the youth?

Yes

Not Applicable

Is this adult the legal guardian of the youth?

Yes

Not Applicable

Who are you remembering? If you are remembering more than one person, please check all appropriate boxes. The person I am remembering is MY:

Spouse/Partner	Child's Parent	Child	Sibling
Mother	Father	Grandmother	Grandfather
Aunt	Uncle	Cousin	Friend
Relationship not listed

Relationship not listed:

Primary Adult Demographic Information

The following demographic information is not used to determine acceptance. This information is used for reporting as means of ensuring equitable access for all.

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-Race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Military Status: Are you an active, reserve, national guard member or veteran?

Yes

Please select military affiliation:

How did you learn about Camp Erin Online?

Eluna social media	Eluna email	Eluna Resource Center
Grief program/center/organization	Therapist/counselor	Friend/family
School	Other media/social media	Other

Other:

Page 4 of 8 - Youth Information

All programming will focus primarily on participants ages 6 and above. Additional considerations can be discussed with a member of the Camp Erin Online team.

If you are registering more than 5 youth, please contact kellypetersohn@elunanetwork.org to register additional youth.

Number of youth attending:

Youth 1 Information

First Name:

Last Name:

What name would this youth like to be called? Does not need to be legal name:

Date of birth:

MM/DD/YYYY

Current grade level (if summer, grade completed):

Grade level other:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-Race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Does youth qualify for free lunch at school?

Yes

The youth is remembering their:

Mother	Father	Sibling	Grandmother
Grandfather	Stepmother	Stepfather	Aunt
Uncle	Cousin	Friend	Relationship not listed

Relationship description

What did this youth call the person who died (i.e. Mommy, Daddy, Papa):

Did this youth attend an end of life/celebration/service?

Yes

No service occurred

Prefer to self-describe

End of life/celebration/service self-description:

Does this youth know the details regarding the cause of death?

Yes

Unsure

Prefer to self-describe

Prefer to self-describe details:

Current or past support (check all that apply):

Has attended an in-person Camp Erin.	Has never received grief, mental health, or behavioral health support.
Currently receiving grief support (i.e., grief center/program/grief counselor).	Currently receiving mental health or behavioral health support (i.e., traditional outpatient therapist).
Has received grief support in the past.	Has received mental health or behavioral health support in the past.
Prefer to self-describe.

Support counseling details:

Does youth have any physical, cognitive, social or mental health considerations that would be helpful for us to know as we support your family?

Please share important details:

Has this youth experienced abuse of any kind? Any details provided will be used to accommodate safety needs of this youth.

Please share any related details:

Special interests/hobbies/personality traits/favorite color:

Any additional information to share:

Youth 2 Information

First Name:

Last Name:

What name would this youth like to be called? Does not need to be legal name:

Date of birth:

MM/DD/YYYY

Current grade level (if summer, grade completed):

Grade level other:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Does youth qualify for free lunch at school?

Yes

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-Race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

The youth is remembering their:

Mother	Father	Sibling	Grandmother
Grandfather	Stepmother	Stepfather	Aunt
Uncle	Cousin	Friend	Relationship not listed

Relationship description

What did this youth call the person who died (i.e. Mommy, Daddy, Papa):

Did this youth attend an end of life/celebration/service?

Yes

No service occurred

Prefer to self-describe

End of life/celebration/service self-description:

Does this youth know the details regarding the cause of death?

Yes

Unsure

Prefer to self-describe

Prefer to self-describe details:

Current or past support (check all that apply):

Has attended an in-person Camp Erin.	Has never received grief, mental health, or behavioral health support.
Currently receiving grief support (i.e., grief center/program/grief counselor).	Currently receiving mental health or behavioral health support (i.e., traditional outpatient therapist).
Has received grief support in the past.	Has received mental health or behavioral health support in the past.
Prefer to self-describe.

Support counseling details:

Does youth have any physical, cognitive, social or mental health considerations that would be helpful for us to know as we support your family?

Please share important details:

Has this youth experienced abuse of any kind? Any details provided will be used to accommodate safety needs of this youth.

Please share any related details:

Special interests/hobbies/personality traits/favorite color:

Any additional information to share:

Youth 3 Information

First Name:

Last Name:

What name would this youth like to be called? Does not need to be legal name:

Date of birth:

MM/DD/YYYY

Current grade level (if summer, grade completed):

Grade level other:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-Race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Does youth qualify for free lunch at school?

Yes

The youth is remembering their:

Mother	Father	Sibling	Grandmother
Grandfather	Stepmother	Stepfather	Aunt
Uncle	Cousin	Friend	Relationship not listed

Relationship description

What did this youth call the person who died (i.e. Mommy, Daddy, Papa):

Did this youth attend an end of life/celebration/service?

Yes

No service occurred

Prefer to self-describe

End of life/celebration/service self-description:

Does this youth know the details regarding the cause of death?

Yes

Unsure

Prefer to self-describe

Prefer to self-describe details:

Current or past support (check all that apply):

Has attended an in-person Camp Erin.	Has never received grief, mental health, or behavioral health support.
Currently receiving grief support (i.e., grief center/program/grief counselor).	Currently receiving mental health or behavioral health support (i.e., traditional outpatient therapist).
Has received grief support in the past.	Has received mental health or behavioral health support in the past.
Prefer to self-describe.

Support counseling details:

Does youth have any physical, cognitive, social or mental health considerations that would be helpful for us to know as we support your family?

Please share important details:

Has this youth experienced abuse of any kind? Any details provided will be used to accommodate safety needs of this youth.

Please share any related details:

Special interests/hobbies/personality traits/favorite color:

Any additional information to share:

Youth 4 Information

First Name:

Last Name:

What name would this youth like to be called? Does not need to be legal name:

Date of birth:

MM/DD/YYYY

Current grade level (if summer, grade completed):

Grade level other:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Does youth qualify for free lunch at school?

Yes

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-Race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

The youth is remembering their:

Mother	Father	Sibling	Grandmother
Grandfather	Stepmother	Stepfather	Aunt
Uncle	Cousin	Friend	Relationship not listed

Relationship description

What did this youth call the person who died (i.e. Mommy, Daddy, Papa):

Did this youth attend an end of life/celebration/service?

Yes

No service occurred

Prefer to self-describe

End of life/celebration/service self-description:

Does this youth know the details regarding the cause of death?

Yes

Unsure

Prefer to self-describe

Prefer to self-describe details:

Current or past support (check all that apply):

Has attended an in-person Camp Erin.	Has never received grief, mental health, or behavioral health support.
Currently receiving grief support (i.e., grief center/program/grief counselor).	Currently receiving mental health or behavioral health support (i.e., traditional outpatient therapist).
Has received grief support in the past.	Has received mental health or behavioral health support in the past.
Prefer to self-describe.

Support counseling details:

Does youth have any physical, cognitive, social or mental health considerations that would be helpful for us to know as we support your family?

Please share important details:

Has this youth experienced abuse of any kind? Any details provided will be used to accommodate safety needs of this youth.

Please share any related details:

Special interests/hobbies/personality traits/favorite color:

Any additional information to share:

Youth 5 Information

First Name:

Last Name:

What name would this youth like to be called? Does not need to be legal name:

Date of birth:

MM/DD/YYYY

Current grade level (if summer, grade completed):

Grade level other:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-Race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Does youth qualify for free lunch at school?

Yes

The youth is remembering their:

Mother	Father	Sibling	Grandmother
Grandfather	Stepmother	Stepfather	Aunt
Uncle	Cousin	Friend	Relationship not listed

Relationship description:

What did this youth call the person who died (i.e. Mommy, Daddy, Papa):

Did this youth attend an end of life/celebration/service?

Yes

No service occurred

Prefer to self-describe

End of life/celebration/service self-description:

Does this youth know the details regarding the cause of death?

Yes

Unsure

Prefer to self-describe

Prefer to self-describe details:

Current or past support (check all that apply):

Has attended an in-person Camp Erin.	Has never received grief, mental health, or behavioral health support.
Currently receiving grief support (i.e., grief center/program/grief counselor).	Currently receiving mental health or behavioral health support (i.e., traditional outpatient therapist).
Has received grief support in the past.	Has received mental health or behavioral health support in the past.
Prefer to self-describe.

Support counseling details:

Does youth have any physical, cognitive, social or mental health considerations that would be helpful for us to know as we support your family?

Please share important details:

Has this youth experienced abuse of any kind? Any details provided will be used to accommodate safety needs of this youth.

Please share any related details:

Special interests/hobbies/personality traits/favorite color:

Any additional information to share:

Page 5 of 8 - Additional Adult Participation Information

Additional adults are welcome to participate in family programming. All participants listed on this form will be expected to participate on the same Zoom screen camera. If you submit the information of an additional participant, you certify that they are 18 years or older and that you have obtained their permission to do so.

Maximum number of additional participating adults is 5.

Number of additional adults (do NOT include the primary adult):

Additional Adult 1 Information

First Name:

Last Name:

Preferred Name:

Date of Birth:

MM/DD/YYYY

Email:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Relationship to youth:

Please list your relationship here:

Is this adult the primary caregiver of the youth?

Yes

Is this adult the legal guardian of the youth?

Yes

Who is this person remembering? If remembering more than one person, please check all appropriate boxes. The adult is remembering THEIR:

Spouse/Partner	Child's parent	Child	Sibling
Mother	Father	Grandmother	Grandfather
Aunt	Uncle	Cousin	Friend
Relationship not listed

Relationship not listed:

Ethnicity/Race (check all that apply)

African American/Black	Asian	Hispanic/Latinx	Multi-Race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Military status: Is this person an active, reserve, national guard member or veteran? 

Yes

Please select military affiliation:

Additional Adult 2 Information

First Name:

Last Name:

Preferred Name:

Date of Birth:

MM/DD/YYYY

Email:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Relationship to youth:

Please list your relationship here:

Is this adult the primary caregiver of the youth?

Yes

Is this adult the legal guardian of the youth?

Yes

Who is this person remembering? If remembering more than one person, please check all appropriate boxes. The adult is remembering THEIR:

Spouse/Partner	Child's parent	Child	Sibling
Mother	Father	Grandmother	Grandfather
Aunt	Uncle	Cousin	Friend
Relationship not listed

Relationship not listed:

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-Race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Military status: Is this person an active, reserve, national guard member or veteran? 

Yes

Please select military affiliation:

Additional Adult 3 Information

First Name:

Last Name:

Preferred Name:

Date of Birth:

MM/DD/YYYY

Email:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Relationship to youth:

Please list your relationship here:

Is this adult the primary caregiver of the youth?

Yes

Is this adult the legal guardian of the youth?

Yes

Who is this person remembering? If remembering more than one person, please check all appropriate boxes. The adult is remembering THEIR:

Spouse/Partner	Child's parent	Child	Sibling
Mother	Father	Grandmother	Grandfather
Aunt	Uncle	Cousin	Friend
Relationship not listed

Relationship not listed:

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-Race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Military status: Is this person an active, reserve, national guard member or veteran? 

Yes

Please select military affiliation:

Additional Adult 4 Information

First Name:

Last Name:

Preferred Name:

Date of Birth:

MM/DD/YYYY

Email:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Relationship to youth:

Please list your relationship here:

Is this adult the primary caregiver of the youth?

Yes

Is this adult the legal guardian of the youth?

Yes

Who is this person remembering? If remembering more than one person, please check all appropriate boxes. The adult is remembering THEIR:

Spouse/Partner	Child's parent	Child	Sibling
Mother	Father	Grandmother	Grandfather
Aunt	Uncle	Cousin	Friend
Relationship not listed

Relationship not listed:

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-Race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Military status: Is this person an active, reserve, national guard member or veteran? 

Yes

Please select military affiliation:

Additional Adult 5 Information

First Name:

Last Name:

Preferred Name:

Date of Birth:

MM/DD/YYYY

Email:

Gender:

Gender self-description:

Pronouns:

Share self-description here:

Relationship to youth:

Please list your relationship here:

Is this adult the primary caregiver of the youth?

Yes

Is this adult the legal guardian of the youth?

Yes

Who is this person remembering? If remembering more than one person, please check all appropriate boxes. The adult is remembering THEIR:

Spouse/Partner	Child's parent	Child	Sibling
Mother	Father	Grandmother	Grandfather
Aunt	Uncle	Cousin	Friend
Relationship not listed

Relationship not listed:

Ethnicity/Race (check all that apply):

African American/Black	Asian	Hispanic/Latinx	Multi-Race
Native American	Pacific Islander	White	Prefer to self-describe

Self-describe ethnicity/race

Military status: Is this person an active, reserve, national guard member or veteran? 

Yes

Please select military affiliation:

Page 6 of 8 - Bereavement Information

Please share information regarding the person(s) you are remembering. If you are remembering more than 5 people, please contact KellyPetersohn@elunanetwork.org to share information regarding additional bereaved.

Number of individuals you are remembering:

Deceased Individual 1 Information

Name of person who died:

Was the deceased an active, reserve, national guard member or retired veteran?

Yes

Unknown

Please select military affiliation:

Cause of Death:

Please list cause of death:

Date of Death:

MM/DD/YYYY format, please estimate as close as possible.

Age at time of death:

Yes

How would you describe your family's communication style about this death?

Open communicationRarely talk about the deathAvoid talking about the deathRefuse to talk about the deathPrefer to self-describe

Family's communication style about death:

Deceased Individual 2 Information

Name of person who died:

Was the deceased an active, reserve, national guard member or retired veteran?

Yes

Unknown

Please select military affiliation:

Cause of Death:

Please list cause of death:

Date of Death:

MM/DD/YYYY format, please estimate as close as possible.

Age at time of death:

Yes

How would you describe your family's communication style about this death?

Open communicationRarely talk about the deathAvoid talking about the deathRefuse to talk about the deathPrefer to self-describe

Family's communication style about death:

Deceased Individual 3 Information

Name of person who died:

Was the deceased an active, reserve, national guard member or retired veteran?

Yes

Unknown

Please select military affiliation:

Cause of Death:

Please list cause of death:

Date of Death:

MM/DD/YYYY format, please estimate as close as possible.

Age at time of death:

Yes

How would you describe your family's communication style about this death?

Open communicationRarely talk about the deathAvoid talking about the deathRefuse to talk about the deathPrefer to self-describe

Family's communication style about death:

Deceased Individual 4 Information

Name of person who died:

Was the deceased an active, reserve, national guard member or retired veteran?

Yes

Unknown

Please select military affiliation:

Cause of Death:

Please list cause of death:

Date of Death:

MM/DD/YYYY format, please estimate as close as possible.

Age at time of death:

Yes

How would you describe your family's communication style about this death?

Open communicationRarely talk about the deathAvoid talking about the deathRefuse to talk about the deathPrefer to self-describe

Family's communication style about death:

Deceased Individual 5 Information

Name of person who died:

Was the deceased an active, reserve, national guard member or retired veteran?

Yes

Unknown

Please select military affiliation:

Cause of Death:

Please list cause of death:

Date of Death:

MM/DD/YYYY format, please estimate as close as possible.

Age at time of death:

Yes

How would you describe your family's communication style about this death?

Open communicationRarely talk about the deathAvoid talking about the deathRefuse to talk about the deathPrefer to self-describe

Family's communication style about death:

Page 7 of 8 - Final Information

Any additional information that we should know to best serve you (i.e. special needs, family customs or cultural aspects to the youth's grieving)?

Do you have any questions for the Camp Erin Online team?

Consents for Participation

IMPORTANT: Each adult participant is required to sign their own consent. The Camp Erin Online team will be in contact to secure consents for any additional youth or additional adults prior to programming. If you need support completing consents, please contact KellyPetersohn@elunanetwork.org.

Camp Erin® Online Photo, Publicity, and Liability Consent and Release

(type name of Parent/Guardian or Adult Participant),

understand that Eluna desires to use certain audio or visual works in which my child or I might appear (e.g., video, screenshots or photographs) and certain information about my child or me, in connection with my child’s or my participation in Camp Erin®’s online programming (“Camp Erin Online”). I understand these audio or visual works may be used to advertise, promote, distribute, market, research, obtain funding for and sell various services, including Camp Erin, Camp Erin Online, and its related activities. I understand that these audio or visual works will not include recordings of certain highly sensitive content that is expressly identified by Eluna as confidential (“Confidential Materials”). I also understand that, as part of my or my child’s participation in Camp Erin Online, I or my child may be exposed to or experience Harm (defined below). By this Consent and Release Agreement (“Consent and Release”), I hereby grant certain rights to Eluna and release Eluna from certain liabilities, on behalf of myself (if I am a participant, employee, volunteer or visitor) or on behalf of my child (if I am the parent or guardian of a minor camper, employee, volunteer or visitor). This Consent and Release confirms my child’s and my grant of rights and our agreement is as follows:

1. Grant of Rights. For good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I, on behalf of myself and my child, hereby grant to Eluna and its directors, officers, employees, agents, representatives, contractors, successors, and assigns the perpetual, irrevocable, royalty-free, non-exclusive, worldwide, sublicensable right and license to: (a) use, edit, reproduce, modify, portray, publish, copy, distribute, create derivative works from, publicly perform and display, without restriction, all or portions of my or my child’s identity and my or my child’s experience at Camp Erin Online, including without limitation my or my child’s name, fictional names (if any), voice, signature, photograph, words and comments, screen captures, image, personality, mannerisms or other likeness of me or my child, and any audio and video recordings of me or my child or remarks and statements made by me or my child, but excluding any Confidential Materials (“Images and Remarks”); and, (b) create other materials or copyright-protected works using or incorporating my or my child’s Images and Remarks in any form or manner, including in any electronic or non-electronic medium now known or later devised, in connection with Camp Erin for advertising, distribution, marketing, promotion, publicity, research, reporting or any other lawful purpose (“Promotional Materials”). I understand that this Consent and Release will cover all of my or my child(ren)’s future participation at any Camp Erin Online activities.

I waive any of my or my child’s right to own, inspect, approve or receive any payment or attribution with respect to any works or Promotional Materials using my or my child’s Images and Remarks, any accompanying written copy or printed matter, or the use to which it is applied. I understand and agree that the Images and Remarks, and Promotional Materials containing or based on my or my child’s Images and Remarks may be used without any restriction as to changes or alterations, and may be modified, used in derivative works, distorted, included in composites or otherwise used in unexpected contexts, manners, or forms, or may not be used at all, and I grant Eluna all necessary rights to do the foregoing. To the extent moral rights in my or my child’s Images and Remarks or any Promotional Materials may not lawfully be waived, I hereby agree not to bring any actions or claims against Eluna therefor.

2. Contact. Unless I opt out below, I agree to receive information/news/updates and other communications in hard copy, via electronic delivery, via telephone, text messaging and other means from Eluna. I hereby consent to collection and disclosure of my mailing address, email address and phone number to Eluna for such purposes, unless I opt out below.

3. Release. I, on behalf of myself and my child, hereby fully and forever release, discharge, and agree to indemnify, defend and hold harmless Eluna and its directors, officers, employees and advisors (collectively, the “Released Parties”) from any and all claims, demands, causes of action, damages (including without limitation direct, indirect, incidental, consequential, special or punitive damages), losses, expenses and liabilities (whether under contractor, warranty or tort, including negligence (whether active, passive, or imputed)) relating to any claim that my child or I may have, now or in the future, based on: (a) any usage or adaptation, whether intentional or unintentional, of my or my child’s Images and Remarks or portions thereof, or works or materials derived therefrom including, but not limited to, claims for libel, defamation, invasion of privacy or rights of publicity, infringement or violation of moral rights or any other right arising out of, or relating to, any use of my or my child’s Images and Remarks, including by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, or based upon any failure or omission to make use thereof; or (b) death, personal injury, property damage, pecuniary or other loss, damage, cost or expense (collectively, “Harm”) that may be suffered by my child, me or any third party as a result of, or in connection with, my or my child’s participation in, volunteering for, or employment by Camp Erin Online.

I AGREE TO INDEMNIFY AND HOLD HARMLESS EACH OF THE RELEASED PARTIES FROM AND AGAINST ANY AND ALL CLAIMS, COSTS, LOSSES, DAMAGES AND EXPENSES (INCLUDING REASONABLE ATTORNEYS’ FEES) INCURRED BY ANY RELEASED PARTY ARISING OUT OF OR IN CONNECTION WITH ANY HARM OR RELEASED CLAIMS. If any provision of this Release is held to be invalid or unenforceable, then that provision shall be severed, and all remaining provisions shall be given full force and effect.

4. Representations and Warranties. I represent and warrant that: (a) my or my child’s involvement or participation in Camp Erin Online is voluntary, (b) I understand that there is a risk of danger or emotional stress as a result of my or my child’s participation in, or volunteering for Camp Erin Online, (c) I further understand that there is the potential for risks and dangers that may not be obvious or reasonably foreseeable at this time related to my or my child’s participation in, or volunteering for Camp Erin Online, and (d) I voluntarily, on behalf of myself or my child, assume the risks, including, but not limited to, those outlined in items (b) and (c) above. I further represent and warrant that I have the power, capacity and authority to grant the rights to Eluna herein granted, that this Consent and Release constitutes my or my child’s legal and binding obligation enforceable in accordance with its terms and that the grants of rights or any portions thereof will not conflict with any similar grants of rights agreements I or my child have made.

5. Disclaimer. I understand that it is possible that Camp Erin Online may include participants with different views and experiences and I agree that I and my child(ren) shall remain respectful and courteous to all others in attendance at all times. I understand and agree that Eluna will not tolerate racist, sexist or otherwise hateful comments or hostile or violent remarks and that Eluna reserves the right to remove and/or ban anyone from Camp Erin Online and other Eluna events for any reason and in its sole discretion.

I understand and agree that Eluna reserves all right, title, and ownership in and to the Images and Remarks, any Promotional Materials containing or based on my or my child’s Images and Remarks, and all other content from Camp Erin Online, and I understand and agree that registering and/or participating in Camp Erin Online does not give me or my child(ren) any ownership rights in such Images and Remarks, Promotional Materials, or other content from Camp Erin Online.

I understand and agree that I will not record, screenshot, take photos of, or otherwise capture or share any or all of Camp Erin Online, including the activities and participants thereof, without the express written permission of Eluna.

I understand and agree that the information presented as a part of Camp Erin Online is offered exclusively as a grief education and recreational service and is not intended and should not be interpreted as a medical service or as offering medical advice.

6. Binding Agreement. This Consent and Release expresses the entire understanding between Eluna, me and my child, and supersedes any prior agreements and discussions between us with respect to the subject matter of this Consent and Release. In granting the rights herein, neither I nor my child have been coerced or induced to do so by any representations or assurances by Eluna or its agents or representatives. This Consent and Release may be amended only by written instrument signed by Eluna and me. The provisions hereof shall be binding upon me, my child and my heirs, representatives, executors, administrators, and successors. Eluna may, in its sole discretion, assign or transfer some or all of this Consent and Release.

7. Governing Law. This Consent and Release will be governed by the laws of the State of Pennsylvania, without regard to its choice of law principles. The parties hereby submit to the exclusive venue and jurisdiction of the state and federal courts of Philadelphia County, Pennsylvania and waive any objection thereto (irrespective of whether the individual signing this Consent and Release changes his or her state of residence).

8. Severability. If any provision of this Consent and Release Agreement is found to be unenforceable in any respect by a court of competent jurisdiction, this Consent and Release Agreement will nonetheless be enforced to the maximum extent to which it is found to be legally enforceable.

9. Construction and Interpretation. For purposes of this Consent and Release, (a) the terms defined in the singular shall have a comparable meaning when used in the plural, and vice versa; (b) the words “include,” “includes” and “including” shall be deemed to be followed by the phrase “without limitation”; (c) the word “or” shall not be exclusive; and (d) references to “written” or “in writing” include in electronic form.

BY SIGNATURE BELOW, I AGREE AND ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD, AND ACCEPTED THIS CONSENT AND RELEASE; THAT THE PROVISIONS CONTAINED HEREIN REPRESENT AN AGREED ALLOCATION OF RISKS WHICH ELUNA IS RELYING UPON; THAT I HAVE SIGNED THIS CONSENT AND RELEASE VOLUNTARILY AND OF MY OWN FREE WILL; AND THAT I HAVE HAD AMPLE OPPORTUNITY TO ASK QUESTIONS REGARDING THE TERMS AND CONDITIONS OF THIS CONSENT AND RELEASE.

Agreed and Accepted: Participant (if over the age of majority in state of residence) or Parent/Guardian of Participant (if Participant is under the age of majority in state of residence).

Adult Participant First and Last Name:

Date:

Youth Participant Name(s) (if applicable):

Please only list the name(s) of youth for which you are a legal guardian.

Youth #1 First and Last Name:

Youth #1 Date of Birth:

Youth #2 First and Last Name:

Youth #2 Date of Birth:

Youth #3 First and Last Name:

Youth #3 Date of Birth:

Youth #4 First and Last Name:

Youth #4 Date of Birth:

Youth #5 First and Last Name:

Youth #5 Date of Birth:

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