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Online Registration Form

Camper's Name(Required)

First Last

Camper's Grade for Spring 2025(Required)

Campers Age in Spring 2025(Required)

Camper's Gender(Required)

Parent/Guardian Name(Required)

Parent/Guardian Cell Phone(Required)

Parent/Guardian Email(Required)

Emergency Contact (name, phone number, and relation to camper)(Required)

Camper's School(Required)

Has Camper Been to Katerpillar Kids Camp Before?(Required)

Camper's T-shirt Size(Required)

Does the camper have any allergies or dietary restrictions?(Required)

Please Explain Allergies or Dietary Restrictions(Required)

Does your camper have any difficulties with disruptive behaviors and what is the best way to manage the disruption? If yes, please explain:(Required)

Please note this will not impact camper’s ability to attend camp

Will your camper have any medications that will be taken at camp?(Required)

Our camp RN will contact any family prior to camp if medication needs are indicated. Please List Medications, dosage and what time medication will need to be administered.

Camper's Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Transportation: Bus Stop at Fort Sanders West:

270 Fort Sanders West Blvd., Knoxville, TN 37922

We provide this transportation for the campers and volunteers. Riding the bus is a great way for the campers to make friends before camp even starts! For a reference on this question, please refer to the FAQ’s for Katerpillar Kids Camp.

The bus stop is at Fort Sanders West located at the intersection of Pellissippi Parkway and Kingston Pike in West Knoxville.
If you choose to drop your child off at Mane Support, the address is:1522 New Hope Road, Rockwood, TN 37854
When you drop your camper off on Saturday morning either at the bus stop or at camp, you will be asked to give a password. When picking your camper up, this password will be used to ensure that the camper is released to the correct family. If someone besides yourself is picking up, please make sure they know the password or the camper will not be released until the volunteers have confirmation of correct password.

I understand that no camper may drive themselves to camp.(Required)

Acknowledged

Saturday, April 26th (7:30am-4:30pm)(Required)

We strongly encourage all campers to ride the bus to meet and begin to bond with their fellow campers and volunteers. The bus stop is at 200 Fort Sanders West Blvd. in the parking lot in front of Building #1

Sunday April 27th (7:30am-4:30pm)(Required)

Bus riders will leave Mane Support at 4:30 each day and would arrive back at the bust stop around 5:15/5:30 for pick up.

Closing Ceremony: At Mane Support

1522 New Hope Road, Rockwood, TN 37854

We invite the families of our campers to the end-of-camp ceremonies. This is a very special time for our campers. Campers show off items they have made and talk a little bit about the weekend and the person they lost. We also have a lot of information to give to parents/guardians regarding other area resources that could be helpful for your family on this grief journey. This time is also a great time for parents/guardians to meet all of the volunteers and campers in your camper’s group.

Grief History

Please provide as many details as possible when answering.

Relationship to Camper(Required)

Name of Person Who Died(Required)

First Last

Age of the Camper at Time of Death(Required)

Date of Death(Required)

Cause of Death(Required)

Where Did the Person Die?(Required)

Please explain location of death(Required)

What was the relationship like between the camper and their loved one who died?(Required)

Was the camper present at the time of death? If yes, please explain circumstances(Required)

Did the camper attend the funeral/memorial service? If no, please explain why(Required)

Has the camper received any professional support? (i.e., psychologist, pastoral counselor, school counselor). If yes, how long was that professional support provided for?(Required)

Have there been multiple deaths of loved ones experienced by this camper?(Required)

Yes

Please explain the nature of those deaths and the relationship of each to the camper(Required)

Any other changes/stresses in the camper’s life at this point in time? (i.e., divorce, illness, relocation, pet death, friends moving away, other(Required)

Please explain the nature of the changes/stresses in the campers life at this point in time(Required)

Katerpillar Kids Camp at Mane Support

Consent, Release and Waiver of Liability, and Agreement

Consent to Attend. I agree the above-named Camper may attend Katerpillar Kids Camp at Mane Support and that Katerpillar Kids may transport the Camper as I have elected. I understand the goal of Katerpillar Kids Camp is to facilitate the grieving process and provide support for the Camper in expressing feelings of grief. Attendance at camp and participation in camp activities is entirely voluntary.

Consent to Photography. I give permission for the Camper to be photographed during his/her participation at Katerpillar Kids Camp.

I understand and agree these photographs are the exclusive property of Covenant Hospice (which organizes Katerpillar Kids Camp) and its related organizations, and I agree Covenant Hospice and its designees may use such photographs for promotional and/or educational purposes, including promotional purposes for Katerpillar Camp and Mane Support. I hereby release Covenant Hospice, its related organizations, and Mane Support, and their directors, officers, employees, and agents, from any liability associated with making, using, or disclosing photographs of the Camper consistent with the foregoing.

Health/Medical Insurance. I certify Camper has health/medical/accident insurance which will provide adequate coverage in the event of Camper's illness or injury at Katerpillar Kids Camp at Mane Support. I further certify all of Camper's recommended immunizations are up to date.

Release and Waiver of Liability. Activities associated with Katerpillar Camp at Mane Support pose certain inherent risks, including damage to property and serious physical illness and/or injury, up to and including death. In consideration of the opportunity for Camper to attend and participate in the functions, activities, and events of Katerpillar Kids Camp and to use the equipment and facilities at Mane Support, the undersigned, for himself/herself and the Camper, acknowledges, understands, and voluntarily agrees to assume all risks associated with Camper's attendance and participation in Katerpillar Kids Camp at Mane Support and hereby releases, waives, forever discharges, and agrees to hold harmless the Releasees (as defined below) from any and all liability, claims, demands, or causes of action the undersigned, the Camper, or any of their heirs, assigns, personal representatives, or next of kin, may have or hereafter acquire for any loss, damage, illness, injury, bodily harm, disability, or death resulting from Camper's attendance and participation in Katerpillar Kids Camp at Mane Support WHETHER OR NOT CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OR OTHER FAULT OF ANY OF THE RELEASEES. "Releasees" means Covenant Hospice, Covenant Health, Mane Support, as well as each of their affiliates, officers, directors, agents, employees, volunteers, sponsors, trustees, and aides.

Medical Care/Emergencies. I hereby give permission to the director of the Katerpillar Kids Camp and Mane Support to provide routine medical care and any health care specified on the Mane Support Health Form, including administration of prescription drugs I have noted on such Form. Further, in the event I cannot be promptly reached in an emergency, I hereby authorize the director of the Katerpillar Kids Camp or his/her designee to obtain emergency services for the Camper, as well as necessary transportation and physician treatment. I also give permission to the Camper's treating physician to order medically necessary services for the Camper.

Agreement. I have read this Consent, Release and Waiver of Liability, and Agreement (the "Agreement") and understand and agree to all its terms. I certify all information I have provided in connection with registration of the Camper, including in this Agreement and the Mane Support Health Form, is accurate and complete. I agree Camper may engage in all Katerpillar Camp activities, except as specifically noted in the Mane Support Health Form. I agree to have my camper comply with current CDC COVID-19 guidelines in place as of September 17 and 18, 2022 regarding day camps and their participants.

Camper's Full Name(Required)

First Last

Campers Date of Birth(Required)

Date(Required)

Signature of Parent/Guardian/Adult Camper(Required)

First Last

Camper Insurance Company(Required)

Group Number

I.D. #:

Phone

Consent to Photograph, Videotape, Film, or Any Other Means of

Recording that Captures Images or Sounds and to Use and Disclosure of the Same

Subject. Relative to the Facility, I am a:(Required)

Current Facility Patient (also obtain HIPAA authorization)

Former Facility Patient (also obtain HIPAA authorization)

Facility Physician, Staff, or Volunteer

Non-Patient Participant in a Covenant Health Program

2. Consent. I hereby consent to and authorize the Facility and its representatives and designees to photograph, videotape, film, or by other means record me (the "Recordings") and use and disclose the Recordings for the purpose described below.

3. Purpose. I understand and agree that the Recordings shall be used and disclosed for the Facility's (and/or its related organizations') public relations, publicity, advertising, or promotional activities. If I am a current or former patient, I have also completed and signed a separate form of Authorization that allows the Facility to use and disclose the Recordings for the purposes described in such Authorization.

4. Venues. I understand and agree that the Recordings may be used for multiple applications, such as print, broadcast media, or on Covenant Health-sponsored Internet sites.

5. Ownership: Compensation. I understand and agree the Facility and/or its related organizations shall be the sole owner of all rights to the Recordings, whether in original format or as edited, subtitled, narrowed, or otherwise altered from time to time, and I understand and agree that I shall have no ownership, copyright, license, or any other property interest whatsoever in the Recordings. I further understand and agree I will not receive any compensation relating to the Recordings (e.g., for the making of the Recordings, for the live or subsequent broadcast of the Recordings, or for the use, disclosure, sale or transfer of the Recordings in any way by Facility or its agents, successors or assignees). I waive any and all rights I may have to any claims for payment or royalties in connection with any exhibition, televising, or other showing of the Recordings, regardless of whether such exhibition, televising, or other showing is under philanthropic, commercial, institutional, or private sponsorship, and regardless of whether a fee of admission, sale price, or rental fee is charged.

6. Release. In consideration of the opportunity to appear in the Recordings, I hereby release Facility and its related organizations (including Covenant Health), and their directors, officers, employees, and agents, from any liability arising from the making, use, and disclosure of the Recordings. In addition, I understand that dissemination of Recordings for authorized marketing purposes may involve unencrypted e-mail transmissions to media outlets at the outlet's request, and I release Facility and its related organizations and representatives from any liability arising from unencrypted media communication

7. Expiration. This consent will expire in six (6) years unless I provide an alternate expiration date or event:

Photography release form signature(Required)

First Last

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Grief History

Katerpillar Kids Camp at Mane Support