Sign-Up for Support Form We will contact you within 24-48 hours to schedule a 30-minute orientation. Sign Up For Support Your Name * First Last * Last Email * Phone * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal 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, February 1, 2021 @ 4:00 PM Monday, March 1, 2021 @ 4:00 PM 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. Please help us avoid spam Submit If you are human, leave this field blank.
