Nevada Donor Network - Register for Camp Cope

Your Name *

First

Last *

Last

Email *

Phone *

Address *

Address

City

State/Province

Zip/Postal

What is your current location?

Southern Nevada

Northern Nevada

Other State

If other, which state?

Employer *

Name of Deceased *

Relationship to the Deceased *

Cause of Death *

Date of Loss *

Details of Circumstance *

Do your children understand the circumstances of the loss? *

Please list all participating family members, including yourself, other adults, teens, and children.

Full Name *

Age *

Birthdate

School & Grade

Gender Identity

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Camp Cope

Is your child participating in Camp Cope at their school? *

Yes

No

If yes, name of school

Camp Cope Permission
My child has my permission to attend Camp Cope sessions with Adam’s Place. I understand that these sessions are strictly peer grief support and are not therapy or counseling. Our emphasis is on coping skills education and support, giving the child a safe confidential place to share.

Name of Parent/Guardian (signature) *

Confirm Signature *

By checking this box, I confirm that I am giving permission and this counts as my signature

Today's Date *

Model Release
In exchange for consideration received, I hereby give permission to Nevada Donor Network and Adam’s Place AKA Camp Cope to use my name and photographic likeness in all forms and media for advertising trade, and any other lawful purposes.

Name of Parent/Guardian (signature)

Confirm Signature

By checking this box, I confirm that I am giving permission and this counts as my signature

How did you hear about Camp Cope? *

ORIENTATION MEETINGS

At our Family Orientation, you will learn more about Nevada Donor Network's Aftercare Program, Adam's Place and Camp Cope. We look forward to meeting you.

You will receive an email with the Zoom invite before Orientation.

My Family will attend the Orientation Meeting on this date: *

Thursday, August 18, 2022 @ 5:30 PM - 6:00 PM

Thursday, August 25, 2022 @ 5:30 PM - 6:00 PM

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Yes, please keep me informed.

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Nevada Donor Network Register for Camp Cope Form

Please list all participating family members, including yourself, other adults, teens, and children.

ORIENTATION MEETINGS

Nevada Donor Network
Register for Camp Cope Form