Register for Camp Cope Family Orientation

Your Name *

First

Last *

Last

Email *

Phone *

Address *

Address

City

State/Province

Zip/Postal

Ethnicity

Are you a veteran?

Yes

No

Is the family income

Do you live within the city limits of Las Vegas?

Yes

No

Do you live within Clark County?

Yes

No

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

Add Remove

Ethnicity

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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 Adam’s Place AKA Camp Cope to use my name in 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 Adam’s Place? *

ORIENTATION MEETINGS

At our Family Orientation you will learn a little more about Adam's Place and our Camp Cope program. We look forward to meeting you. Family Orientation is scheduled throughout the school year and is held virtually on Zoom. You will receive an email with the Zoom invite before the Orientation.

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

Monday, January 9, 2023@ 4:00 PM - 4:30 PM

Monday, February 6, 2023@ 4:00 PM - 4:30 PM

Monday, March 6, 2023 @ 4:00 PM - 4:30 PM

Monday, April 3, 2023 @ 4:00 PM - 4:30 PM

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