Camp Dragonfly Bereavement Registration Please fill out the form below. To be completed by the legal guardian: Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Alt. PhoneEmail(Required) Re-enter Email(Required) Has the child experienced multiple deaths?(Required) Yes No If yes, please explain:Media Release - I grant permission for photographs/videos, written evaluation comments, and or interviews with me (or my child/teen) to be used for educational purposes and/or to promote future events.(Required) Yes No By checking this box, you are electronically signing and authorizing the use of the above materials to be used in the ways listed above.Child Registration Please complete with your childChild RegistrationChild's nameAge of childName of family member lostRelationship of loved one to guardian/child:Date of lossCause of Death Add RemoveThe following questions are optional. However they help us to secure grant funding for future programs and camps.How did you hear about this? Mail Radio Facebook Word of mouth Website Was your loved one a patient here at Androscoggin Home Healthcare + Hospice?YesNoPlease indicate: gender, race, and primary language. Please also include payor source i.e. Mainecare, Medicaid, or Commercial (if there is no insurance please indicate uninsured).EmailThis field is for validation purposes and should be left unchanged. Δ