2024 Camp Lifetimes Registration Form
Grief Sharing and Education Camp

June 26, 2024

9 a.m. to 3:30 p.m.

Lory's Place

Camp is for students entering kindergarten through fifth grade

One participant per registration form

Camp Participant Information

First / Last Name *

Age *

Grade

Gender *

Primary Guardian Information

Name *

Relationship *

Address *

City *

State *

Zip *

Preferred phone number *

Cell phone

Work phone

E-Mail Address *

Information Regarding the Person(s) who died

Name *

Age

Birth date

Date of death

Died at *

She / He was my child's

Causes, circumstances, and location of death

What other significant deaths have you experienced and approximate date(s)?

Was your child involved in the burial, funeral, or memorial service?

Yes

No

Any concerns you have regarding your child?

Providing the following information is optional but is extremely helpful to Lory's Place for use in research and funding needs.

County you live in

School district

How did you find out about camp lifetimes? (Check all that apply)

Ethnic background of child

Emergency Contact Information (other than guardian)

First / Last Name

Relationship to participant

Address

City

State

Zip

Home phone

Cell phone

Work phone

Emergency Medical Information

MEDICATIONS

Please list any medications(s) your child is currently taking: Name of and Reason for the Medication

ALLERGIES

List all known allergies and describe reaction

To best meet the needs of your child, please indicate if there is any other medical condition we should be aware of

Insurance Information

Is the participant covered by a hospital or health insurance plan?

Yes

No

If so, indicate carrier or plan name

What is the Group # of the insurance?

Read Before Submitting

As authorized by my signature below, I affirm that I am the parent or legal guardian of the person listed on this form as Participant and that I am legally authorized to, and give consent on behalf of, the Participant to participate in the Camp Lifetimes summer programming events and activities, including transportation (the “Program”). I authorize Corewell Health, and its corporate affiliates (collectively “Corewell Health”), to utilize any photographs, personal narratives, interviews, audio and/or video recordings of the Participant in any Corewell Health publications (paper and electronic) and events. In the event of Participant’s illness or injury while attending and/or participating in the Program, I hereby consent to and authorize Corewell Health’s staff and volunteers to provide or secure medical treatment for the Participant and, if necessary, arrange for transportation to a medical facility. In the event I cannot be reached in an emergency, I hereby consent to the physician/provider selected by the event organizers to secure and administer medical treatment to the Participant. On behalf of myself, the Participant, and our heirs, executors, administrators, successors and assigns, I release, discharge, and hold harmless Corewell Health, its employees, officers, directors, and volunteers from any and all claims, demands, damages, and causes of action, whether the same are known or unknown, anticipated or unanticipated, resulting from, or arising out of, the Program on June 26, 2024. *

By checking this box I agree to the terms above.

The 2024 Camp Lifetimes will be partnering with Forest Meadow Ranch to provide a unique equine experience. In order to participate please to read the complete waiver and sign below:
Equine Activity Release and Liability Waiver & Photo Release
I, _________________________________acknowledge I am voluntarily engaging in equine- assisted psychotherapy and/or learning activities with Forest Meadow Ranch, LLC. I understand that anyone engaging in equine activities can suffer bodily injury, including death, due to the unpredictable, dangerous, and powerful nature of horses, including potential for injury which can occur from caring for horses or being involved in therapeutic/learning activities that include horses. Because of the potential benefits of the equine assisted psychotherapy, I hereby waive all claims which I, my heirs and assigns, executors, administrators, agents, insurers, or anyone else associated with me, may have at any time against, Forest Meadow Ranch, LLC officers, employees, instructors, therapists, aides, volunteers, contract personnel, insurers, and/or anyone else associated with Forest Meadow Ranch, LLC arising out of any injury or damages which may sustain as a result of my involvement in the equine program.

II. The undersigned assumes any and all risks associated with horse-related activities, including but not limited to bodily injury and other physical harm. In consideration, therefore, for the privilege of working and/or participating in activities around horses, the undersigned agrees to hold harmless and indemnify Forest Meadow Ranch, LLC, officers, employees, instructors, therapists, aides, volunteers, and/or contract personnel from and against any all claims associated or connected with my participation in Forest Meadow Ranch activities.

III. To the maximum extent allowed by law, the undersigned further releases Forest Meadow Ranch, LLC officers, employees, instructors, therapists, aides, agents insurers, volunteers and/or contract personnel from any liability or responsibility for accident, damage, injury, or illness to the undersigned or to any family member of spectator accompanying the undersigned on any Forest Meadow Ranch, LLC related premises.

IV. I have read and fully understand this Release and Hold Harmless Agreement. I freely and voluntarily enter into the Release and Hold Harmless Agreement with Forest Meadow Ranch, LLC, understanding that this Release and Hold Harmless Agreement is a waiver of any and all claims and liability(ies). Person voluntarily entering into this Release and Hold Harmless Agreement.

Please sign and date: *

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