Camper's First Name: Camper's Last Name: Birth Date: / / Camper's Age: Gender: Cisgender Man Cisgender Woman Transgender Man Transgender Woman Non-binary, gender-queer, two-spirit, intersex Prefer to self-idenity Prefer not to say What school does your child attend? Grade 2025-26 Email (Please enter the email you would like registration confirmation emails sent to): Address: City: State: Alabama Alaska Arizona Arkansas 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 American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Parent/Guardian Name: Parent/Guardian Email (if different from above): Parent/Guardian Phone: Parent/Guardian Address: (if different from child): Emergency Contact Name (if Parent/Guardian cannot be reached): Emergency Contact Number: Emergency Contact Relationship to Participant: Who may drop off and pick up your camper? What is their relationship to your camper? Has your child attended any ACTR grief camp before? Yes No If so, what was your child's first year at ACTR? Name of deceased person: Relationship to child: Cause of death: Date of death: What would be helpful for us to know about the circumstances of the death and your child's response? Or, have any of the circumstances in your family shifted lately? How does your child do in school or group settings? Has your child ever attempted or expressed a desire to harm themselves or anyone else? (including thoughts about suicide, fights on the playground, cutting, etc.)? If yes, please explain. Has your child had past counseling/group experience? Has your child seen a professional to address mental health concerns within the past 12 months? If yes, please explain: Please check any special considerations, circumstances, needs or requests that your child may have. Has your child received in-school or out-of-school suspension, been assigned by the school or other authorities to a restrictive placement for behavioral/disciplinary reasons, or been involved in a legal infraction? If yes, please explain: What works best if your child is struggling (with rules, structure, homesickness, anxiety, other)? What are your child interests? What are you and your child's hopes/goals for attending this program? Please list ANY/ALL food allergies or restrictions: Anything else we should know to help ensure a positive experience for your camper? (2025) Race/Ethnicity Black, African, or African American East Asian or South Asian Hispanic or Latinx/a/o Indigenous / First Nations Middle Eastern or North African Native Hawiian or Other Pacific Islander White/Non-Latinx or Caucasian Other Multiple races Prefer not to answer (2025) Do you live in a rural area? (2025) Do you identify with any of the following? (2025) Has a family member or loved one died by suicide? (2025) TGRC has received funding to support families & individuals bereaved by COVID-19. Do you know someone who has died as a result of COVID-19? (2025) Is your family eligible for free school lunches, Medicaid, Healthy MT Kids, SNAP benefits, or other state or federal assistance programs? (2025) If YES, which programs? Name of Parent/Guardian signing waiver: