Sign-up for Support - Adams Place

Your Name *

First

Last *

Last

Email *

Phone *

Address *

Address

City

State/Province

Zip/Postal

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

Please wait a moment after clicking Add/Remove for the new field set to appear/disappear.

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? *

Our orientation meetings are scheduled throughout the school year with a limited number of families per meeting. Only meetings that are not yet full are shown below. Once a meeting is fully booked, it will no longer show as an option in this form. If no dates are shown it indicates that all orientation dates are currently full at this time.

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

Monday, April 5, 2021 @ 4:00 PM

Monday, May 3, 2021 @ 4:00 PM

Meeting times can occasionally change. We suggest checking the site calendar to confirm on your selected date.

Join Our Email List?

Yes, please keep me informed.

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Sign-Up for Support Form

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