Healing Pathways Events – Supporting Kidds

Which upcoming event are you registering for?

Caregiver Information

Your Name

First

Last

What is your relation to the children you will be registering?

Email

Cell Phone

Would you like to receive text messages from Supporting Kidds about upcoming events and important updates?

Yes, I’d like to receive text messages.
No, I prefer not to receive text messages.

We promise not to send spam- just helpful event notifications and reminders. You can opt out at any time!

Home 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

Child 2 Name

First

Last

Child 2 Age

Child 2 Gender

Child 3 Name

First

Last

Child 3 Age

Child 3 Gender

Child 4 Name

First

Last

Child 4 Age

Child 4 Gender

Child 5 Name

First

Last

Child 5 Age

Child 5 Gender

Child 6 Name

First

Last

Child 6 Age

Child 6 Gender

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:

Clear Signature

Date