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Hospice Atlanta Overview
Private Home Care
- Private Home Care Services
- Private Home Care FAQ
About Us
Get Involved
- Make a Donation
- Volunteer
  - Volunteer Interest Form
  - Volunteer Application
Contact Us

Camp STARS InTown Application

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- Camp STARS InTown – March 16th
- Camp STARS InTown Application
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Hospice FAQ

Camp STARS InTown Application

Thank you for your interest in Camp STARS InTown 2019! We look forward to you joining us. Please complete this application to register. Questions? Please contact us at 404-869-3072 or via email.

(*) denotes a required field

Name of Person Completing Application*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone #*
Email*
Loss History
Name of the Deceased*
Age of the Deceased*
Date of Death*
Month
Day
Year
Cause of Death*
Camp STARS InTown Applicants
How many family members, including yourself, will be attending Camp STARS InTown?*
ATTENDEE #1
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #2
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #3
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #4
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #5
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #6
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #7
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #8
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #9
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #10
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #11
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #12
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #13
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #14
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #15
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #16
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #17
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #18
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #19
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #20
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #21
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #22
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #23
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #24
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
ATTENDEE #25
Name*
First Last
Sex*
- Male
- Female
Age Group/Facilitated Group (choose one)*
Relationship to the Deceased*
Other Information
Is there anything else you would like us to know about how your family is coping with the loss?
Do you have any other questions?
How did you hear about Camp STARS InTown?*
- Family Member
- Friend
- School Counselor
- Place of Worship
- Internet Search
- Visiting Nurse | Hospice Atlanta Website
- Media
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As Georgia’s leading nonprofit hospice provider, you can count on Hospice Atlanta to give your entire family physical, emotional and spiritual support when a loved one is facing a life-limiting illness.

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Atlanta, GA 30328

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