Supporting Kidds Family Information and Consent Form (Schools)

Supporting Kidds, The Center for Grieving Children and Their Families is a non-profit organization providing individual and group based bereavement support programs and services throughout the state of Delaware.

School Name

Please provide the name of your child(ren)’s school.

Parent/Guardian Name

First

Last

Phone

Email

Race/Ethnicity

Zip Code

Child #1 Name

First

Last

Child # 1 Date of Birth

Child #2 Name (if applicable)

First

Last

Child # 2 Date of Birth (if applicable)

Child #3 Name (if applicable)

First

Last

Child # 3 Date of Birth (if applicable)

Child #4 Name (if applicable)

First

Last

Child # 4 Date of Birth (if applicable)

Child #5 Name (if applicable)

First

Last

Child # 5 Date of Birth (if applicable)

Have you experienced the death of a significant person in your life?

Yes
No

Deceased Information

Who Died?

Example: Parent, sibling, aunt, uncle, cousin, grandparent, etc.

When did they die?

Date of Death

How did they die?

Example: Cancer, heart disease, overdose, COVID-19, lung disease, murder, suicide, accident etc.

I DO give my consent for my child(ren) to participate in Supporting Kidds programs and services.

Yes
No

Photo of the Deceased

Click or drag files to this area to upload. You can upload up to 4 files.

Please provide a photo (or multiple photos if applicable) of the deceased for a surprise, personalized gift that each child will receive at the end of the group session.

Signature

Relationship to Child(ren)

Date