Camp Blue Butterfly - Camper Registration

Please do not print this application. Must be filled out and submitted online. THE APPLICATION WILL LIKELY TAKE 20-30 MINUTES TO COMPLETE. YOU WILL NEED TO ATTACH A JPEG PHOTO OF YOUR CHILD'S SPECIAL PERSON TO COMPLETE THE APPLICATION. ALL APPLICATIONS MUST BE RECEIVED BY JULY 31, 2025. YOU WILL HEAR BACK FROM US VIA EMAIL OR PHONE BY AUGUST 15, 2025. A SEPRATE APPLICATION IS *REQUIRED* FOR EACH CHILD ATTENDING.

All Campers must be between the ages of 9-17 at the time of camp: September 5-7, 2025 (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*

MaleFemaleOther
Birthdate*

MonthDayYear
Age at Time of Camp (September 5-7, 2025)*

9-10 years old11-12 years old13-14 years old15-17 years old
Please provide the grade the child will enter in the fall of 2025:
Child's T-Shirt Size*

Child SmallChild MediumChild LargeAdult SmallAdult MediumAdult LargeAdult XL
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:*

Cell PhoneWork PhoneHome Phone (land line)
Second Phone Number

Area CodePhone Number
This phone is a:

Cell PhoneWork PhoneHome Phone (land line)
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:

Cell PhoneWork PhoneHome Phone (land line)
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?

YesNo
Please provide the Name, Relationship, Date of Death, and Cause of Death for any additional Special People:
Describe how your child shows his/her grief (please provide examples of behavior):*
What, if any, changes have you noticed in your child's behavior since the death of their Special Person? Have these created any problems at home or school? Please be specific:*
Describe how your child responds to authority. Are there any discipline concerns we should be aware of? Has he/she been disciplined at school for behavior problems? Please be specific:*
Have there been any other significant changes in the child's life (i.e.: moving to a new home, school, divorce) other than the death of their Special Person? Please be specific:*
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?*

YesNo
Please expalain:
Has your child experienced any challenges at school?*

YesNo
Please expalain:
Has your family been involved with other counseling (counseling. special school programs, etc)?*

YesNo
Please expalain:
Does your child have any physical limitations?*

YesNo
Please expalain:
Has your child ever been away from home overnight (without a parent/guardian)?*

YesNo
Please expalain:
Does your child have any problems with bed wetting?*

YesNo
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 none, put N/A)*
This child's swimming ability is...*

Poor Swimming AbilityGood Swimming AbilityExcellent Swimming AbilityDo Not Know Swimming Ability
Illnesses and Medical Complications Past or Present (check all that apply)*

Respiratory ProblemsSeasonal AllergiesFood AllergiesMedicine AllergiesTopical Allergies (lotion, sunscreen, etc.)Dizzy Spells and/or FaintingBack ProblemsSeizure DisordersAnaphylactic ShockBalance ProblemsAsthmaADD or ADHDHypoglycemiaHeart or Circulation ProblemsPulmonary EdemaType 1 DiabetesType 2 DiabetesInsect Bite Allergies (i.e. mosquitoes, bees, etc.)Recent SurgeryRecent Broken BonesNONEOther
Please explain each medical issue you checked above.
What, if any, specific activities should be DISCOURAGED for medical reasons while at camp?
NON-PRESCRIPTION Medications / Treatments: that you APPROVE the medical team to administer at camp.*

Sunblock/SunscreenInsect RepellentLip BalmRash OintmentAcetaminophenIbuprofenAntiseptic OintmentBand-aidsAnti-Itch CreamHydrogen PeroxideRubbing AlcoholCough SyrupCough DropsDecongestantAntihistamineMelatoninOther
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, September 5 - Sunday, September 7, 2025). ALL prescription medication will be provided in the labeled bottle provided by the pharmacy. I authorize Empath Health contracted medical staff to administer the medications.*

Yes, I understand that sharing medical info, medications, and dosages are my responsibility.No, I do not understand that sharing medical info, medications, and dosages are my responsibility.
Prescription or Over-the-Counter Medication #1
Prescription Medication 1: Reason for taking, DOSAGE, and Time(s) of Day to Administer
How long as child been taking Medication #1? (Be specific.)
Prescription or Over-the-Counter Medication #2
Medication 2: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long has child been taking Medication #2? (Be specific.)
Prescription or Over-the-Counter Medication #3
Medication 3: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long as child been taking Medication #3? (Be specific.)
Prescription or Over-the-Counter Medication #4
Medication #4: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long as child been taking Medication #4? (Be specific.)
Prescription or Over-the-Counter Medication #5
Medication #5: Reason for taking, DOSAGE, and Time(s) of Day to Administer (Be specific.)
How long has child been taking Medication #5? (Be specific.)
Side effects of the prescription drugs, vitamins, or over-the-counter medications sent to camp?
Additional information we need to know about the above prescription drugs, vitamins, or over-the-counter medications sent to camp - or - additional medications, if any.
Primary Doctor*

First NameLast Name
Doctor's Phone Number*

Area CodePhone Number
Please upload a photo of the camper's Special Person. 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 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 2025 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 September 5, 6, and 7, 2025, 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