Camp Blue Butterfly - Camper Registration

Please do not print this application. This application must be filled out and submitted online. THE APPLICATION WILL TAKE APPROXIMATELY 20-30 MINUTES TO COMPLETE. YOU WILL NEED TO ATTACH A JPEG PHOTO OF YOUR CHILD'S SPECIAL PERSON TO COMPLETE THE APPLICATION. Applications will be received on a rolling basis, applications will be approved first come first serve. Submission of your application does not guarantee participation in Camp Blue Butterfly, spaces are limited. Receipt of your application will be sent via email. A separate application is *required* for each child attending.

All Campers must be between the ages of 8-17 at the time of camp: November 13-15, 2026 (there are a few exceptions to this). The drop-off/pick-up location is Day Spring Episcopal Conference Center, 8411 25th St E, Parrish, FL 34219.
Questions?

If you have questions or concerns about Camp Blue Butterfly please contact us at CampBlueButterfly@empathhealth.org or 941.893.6610
Name of Caregiver Filling Out This Application

First NameLast Name
Relationship to Child
Child's Information
Child's Name

First NameLast Name
Preferred Name (if child has one)
Gender

Other
Birthdate

MonthDayYear
Age at Time of Camp (November 13-15, 2026)
Please provide the grade the child will enter in the fall of 2025:
Child's T-Shirt Size
Parent/Guardian Information
Home Mailing Address (for camp correspondence)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent or Guardian #1 (this person will receive correspondence regarding child)

First NameLast Name
Relationship to Child
Best Phone Number

Area CodePhone Number
This phone is a:
Second Phone Number

Area CodePhone Number
This phone is a:
Parent/Guardian #1 Email Address (if a group home please give group home manager's email)
Parent or Guardian #2

First NameLast Name
Relationship to Child
Parent or Guardian #2 Best Phone Number

Area CodePhone Number
This phone is a:
Parent/Guardian #2 Email Address
Emergency Contact

Other than Parent/Guardian
Who is an Emergency Contact?

First NameLast Name
Relationship to Child
Cell Number for Authorized Adult

Area CodePhone Number
SECOND authorized adult.

First NameLast Name
Relationship to Child
Cell Number For Authorized Adult

Area CodePhone Number
Background/Behavior Information

Please fill this out to the best of your ability. All information shared is confidential. Camp Blue Butterfly staff want to make sure this child as well as other campers have a safe, healthy, fun time at camp. This information is extremely helpful and is only shared with camp staff on a "need to know" basis.
Name of Camper's Special Person who died:

First NameLast Name
Special Person's Relationship to Camper:
Date of Death

MonthDayYear
Date
Cause of Death:
Does the camper have more than one Special Person who has died?
Please provide the Name, Relationship, Date of Death, and Cause of Death for any additional Special People:
How would your child describe how their special person(s) died?
Describe how your child shows his/her grief (please provide examples of behavior):
PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR ABILITY. IF THE ANSWER IS "YES" TO ANY QUESTION, PLEASE PROVIDE AN EXPLAINATION:
Has the child ever received a behavioral and/or mental health diagnosis?
Please expalain:
Has your family been involved with other counseling (counseling (not Blue Butterfly). special school programs, etc.)?
Please expalain:
Does your child have any physical limitations, especially those that would limit their participation in camping or outdoor activities?
Please expalain:
Has your child ever been away from home overnight (without a parent/guardian)?
Please expalain:
Does your child have any problems with bed wetting?
If child does wet the bed, please explain (i.e. wears pull-ups, don't drink liquids after certain time, just need to be aware, etc.)
Is there anything additional that you feel we should be made aware of?
Medical History + Prescription Medication Information
List ALL known ALLERGIES to food, plants, medications, animals, etc. (If no known allergies, please indicate "None").
This child's swimming ability is...
Illnesses and Medical Complications Past or Present (check all that apply)

Other
Please explain each medical issue you checked above.
What, if any, specific activities should be DISCOURAGED for medical reasons while at camp?
Prescription & Over-the-Counter Medications

If your child is NOT taking any prescription or over-the-counter medications, vitamins, or inhalers to camp, please type "NONE" in each of the boxes.
I understand that it is my responsibility as a caregiver to make sure that all instructions are clear and that the necessary dosage is adequately supplied for the duration of camp (Friday, November 13 - Sunday, November 15, 2026). ALL daily prescription medications will be provided in the labeled bottle provided by the pharmacy and over-the-counter medications will also be provided and labeled at check-in. I authorize Empath Health contracted medical staff to administer the medications. I understand that general first aid will be provided, as needed, by certified medical staff throughout the camp weekend.

Please share the following information regarding prescription medications for the child:

Rows	Medication Name	Reason for Taking	Dosage	Time(s) of Day to Administer	How long has the child been taking this medication?	Please share any expected side effects:
Medication 1
Medication 2
Medication 3

Primary Doctor

First NameLast Name
Doctor's Phone Number

Area CodePhone Number
Please upload a photo of the camper's Special Person. The photo will be used as part of art projects and a memorial event. **Upload a JPG ONLY...do NOT upload a PDF or other file type **. You will not be able to upload a photo larger than 1 MB (or 1024 KB) in size.

Upload a File

Cancelof
Permission

This health history is correct so far as I know, and the above named minor has permission to engage in all prescribed program activities, except as noted. The undersigned do hereby authorize the leadership of Camp Blue Butterfly, or such substitute as they may designate, as agent for the undersigned to consent to: X-Ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care for the above minor, which deemed advisable by, and to be rendered under the general or special supervision of any physician and surgeon, licensed under the provision of the Medicine Practice Act or any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, camp or elsewhere. This authorization will remain effective while the above minor is en-route to and from camp, involved or participating in any camp program, unless revoked in writing by the undersigned and delivered to the Manager of Empath Blue Butterfly Children's Grief Care as legal guardian/social worker/other. My permission is given for the minor named in this application to attend Camp Blue Butterfly in the fall of 2026 located at Day Spring Episcopal Conference Center, 8411 25th St E, Parrish, FL 34219.
Name

First NameLast Name
Date

MonthDayYear
RELEASE OF LIABILITY:

In consideration of attending Camp Blue Butterfly on November 13, 14, and 15, 2026, I understand and agree that Empath Health, its Board of Directors, Officers, Employees, and Volunteers are released from any legal responsibility and/or liability for negligence arising out of any accidents or illnesses which occur while attending Camp Blue Butterfly.
Name

First NameLast Name
Date

MonthDayYear
PUBLICITY PERMISSION:

I hereby consent that Empath Health and its affiliate programs be authorized to use my child's name, title, portrait, picture, video image, photograph, or any reproduction likeness of my child or quotation of their remarks, for public information, fund-raising purposes and use of the other programs as approved by Empath Health. Permission is hereby granted to use personal information about myself, my family, and the circumstances for our relationship with Camp Blue Butterfly as deemed appropriate by Empath Health or the above named entities for the same purposes.
Name

First NameLast Name
Date

MonthDayYear
CONSENT FOR MINOR

I represent that I am the parent and/or guardian of the minor named below and represent that I have the legal authority to execute the foregoing consent release:
Name of Camper

First NameLast Name
Name

First NameLast Name
Date

MonthDayYear
Signature of Parent/Guardian
DISCLAIMER

Submission of this application does not guarantee participation in Camp Blue Butterfly. ALL potential campers and their families will be contacted for a required intake assessment before final camp enrollment. If you have any questions please reach out to CampBlueButterfly@empathhealth.org.
Should be Empty:

Questions?

Child's Information

Parent/Guardian Information

Emergency Contact

Background/Behavior Information

Medical History + Prescription Medication Information

Prescription & Over-the-Counter Medications

Permission

RELEASE OF LIABILITY:

PUBLICITY PERMISSION:

CONSENT FOR MINOR

DISCLAIMER