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Which upcoming event are you registering for?
*
Coping with the Holidays – Wednesday, November 20 6:30-8:00pm
Caregiver Information
Your Name
*
First
Last
What is your relation to the children you will be registering?
*
Email
*
Phone
*
Are any additional adults attending with you?
*
Yes
No
If yes, please list the adult's name and relation to the children.
*
Child Information
How many children are you registering for this event?
*
Child 1 Name
*
First
Last
Child 1 Age
*
Child 1 Gender
*
Select
Female
Male
Non-Binary
Transgender
Prefer Not to Say
Child 2 Name
*
First
Last
Child 2 Age
*
Child 2 Gender
*
Select
Female
Male
Non-Binary
Transgender
Prefer Not to Say
Child 3 Name
*
First
Last
Child 3 Age
*
Child 3 Gender
*
Select
Female
Male
Non-Binary
Transgender
Prefer Not to Say
Child 4 Name
*
First
Last
Child 4 Age
*
Child 4 Gender
*
Select
Female
Male
Non-Binary
Transgender
Prefer Not to Say
Child 5 Name
*
First
Last
Child 5 Age
*
Child 5 Gender
*
Select
Female
Male
Non-Binary
Transgender
Prefer Not to Say
Child 6 Name
*
First
Last
Child 6 Age
*
Child 6 Gender
*
Select
Female
Male
Non-Binary
Transgender
Prefer Not to Say
Additional Information
Name of Deceased
*
First
Last
What was their relation to the children?
*
What was the cause of death?
*
Media Release
To communicate Supporting Kidds’ mission and message, to educate the community about children and grief, and report program outcomes to funders, we often use quotations, stories, artwork, and photos for brochures, newsletters, lectures, training, newspaper articles, our website, and other forms of media. Last names and detailed information are omitted from these materials.
I give permission for Supporting Kidds to use photos of my family for the purposes described above.
Yes
No
I give permission for Supporting Kidds to use my family's artwork, quotations, and stories for the purposes described above.
Yes
No
Next Steps…
Have you completed a formal consultation with the Clinical Director for services at Supporting Kidds?
*
Yes
No
If you have not completed a consultation, this form will take you to our Family Information Sheet after clicking “Submit” below.
Please sign here to signify that you give your child permission to participate in Supporting Kidds groups and events:
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Clear Signature
Date
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