Camp Dragonfly Bereavement Registration

Please fill out the form below.

To be completed by the legal guardian:
Has the child experienced multiple deaths?(Required)
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)
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 child
Child Registration
Child's name
Age of child
Name of family member lost
Relationship of loved one to guardian/child:
Date of loss
Cause of Death

The following questions are optional.

However they help us to secure grant funding for future programs and camps.
How did you hear about this?
This field is for validation purposes and should be left unchanged.