Southeastern Health

Camp Care Registration Form

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If you are interested in enrolling your child in Camp Care which will be held on May 20, 2017, please complete the following fields and click “submit.” This form may be used by a parent or guardian, family member, school personnel, or anyone wishing to assist a child ages 8-16 who is experiencing grief. Early registration is preferred and interview/photo may be arranged by appointment. Camper and Parent or Guardian must be present at interview. Permission for Participation, Medical History and Activity Releases are signed by the legal Parent or Guardian. The Security Photo ID of the child must be gained by permission. Those not completing Early Registration by Interview and photo will be required to attend Parent/Camper Registration Night on May 9th from 4-6pm at Southeastern Home Care Services in order to participate.

To complete Registration, we ask that you provide:

  • Insurance Card (Medicaid/Private/etc.) – Card will be photocopied for information including policy number.
  • Social Security Number for the child
  • Immunization Record or knowledge of completion dates for shots including dates of last Tetanus shot.
  • Phone Number Information – Must provide accurate phone contact information and two alternate numbers. These numbers are required for the possibility of emergency use during the Camp Care event.
  • Medicines, or an accurate list of medicines, that the camper will have to take during the Camp Care event.
  • Digital Photo – A photo can be taken at the Registration Interview, or you may take one with camera/cell phone (Head and Shoulders), and email it to This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Click here to download the Brochure

This application must be received by the April 28, 2017 deadline in order to be fully considered for the opportunity of Camp Care.

Mail to:
Attn: Rev. Dean Carter

Southeastern Hospice

2002 North Cedar Street

Lumberton, NC 28358

Or fill out, scan and email to: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Last Updated ( Wednesday, 01 February 2017 16:18 )  

Contact Information
Mailing Address:
PO Box 1408  
Lumberton, NC 28359
Contact Person:
Chaplain Dean Carter
Pastoral Care
Tel: (910) 671-5031
Fax: (910) 671-1757
carter02@srmc.org

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Mailing Address: P.O. Box 1408,
300 West 27th St., Lumberton
NC 28359

Tel: (910) 671-5000

Guest Services Messages:
GuestSerFB@srmc.org

General Messages:
crabtr01@srmc.org@srmc.org

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