Family Registration for Grief Support Groups Family Registration for Grief Support Groups Step 1 of 4 25% Personal InformationName* First Last Check which applies to you:* Mother Father Grandmother Grandfather Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneCell Phone*Email* Information about the DeceasedName* First Last Date of Death*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age at Death*Relationship of deceased to child(ren)* Father Mother Brother Sister Grandfather Grandmother Son Daughter Cousin Relationship of deceased to parent/guardian* Father Mother Brother Sister Grandfather Grandmother Aunt Uncle Cousin Cause of Death* Cancer Terminal Illness Automobile Accident Suicide Homicide Accidental Multiple Losses Are you the legal guardian/caretaker of the child(ren)?* Yes No How many children would you like to enroll?*Please enter a number from 1 to 5. Child 1: InformationChild 1: Name* First Last Child 1: Sex* Male Female Child 1: Age*Child 1: Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child 1: Grade*Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeDoes Child 1 have any food allergies? If so, list them below:Child 2: InformationChild 2: Name* First Last Child 2: Sex* Male Female Child 2: Age*Child 2: Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child 2: Grade*Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeDoes Child 2 have any food allergies? If so, list them below:Child 3: InformationChild 3: Name* First Last Child 3: Sex* Male Female Child 3: Age*Child 3: Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child 3: Grade*Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeDoes Child 3 have any food allergies? If so, list them below:Child 4: InformationChild 4: Name* First Last Child 4: Sex* Male Female Child 4: Age*Child 4: Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child 4: Grade*Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeDoes Child 4 have any food allergies? If so, list them below:Child 5: InformationChild 5: Name* First Last Child 5: Sex* Male Female Child 5: Age*Child 5: Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child 5: Grade*Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeDoes Child 5 have any food allergies? If so, list them below: Additional QuestionsDo any of the child(ren) feel that the death is their fault?* Yes No Please list the names of the child(ren) that feel this way:How was the death explained to the child(ren)?*Did the child(ren) view the body?* Yes No Did the child(ren) attend the funeral?* Yes No Do you freely discuss the deceased person and death with the child(ren)?* Yes No Do you have family or friends with whom you can talk?* Yes No Do you or the children have any other support groups?* Yes No Please list the support groups below:Has/Have the child(ren) lost any other loved ones (including friends & pets)?* Yes No Please indicate the relationship and the date of loss:Has your family moved recently?* Yes No Have there been any changes in the child(ren)'s environment (school, work, home)?* Yes No Please describe the changes:What moods/emotions is your family feeling as a whole?* Shock Fear Denial Sorrow Anger Guilt Regret Check all that apply.Has/Have the child(ren) developed fears or anxieties that were not present before the death?* Yes No Please explain the fears or anxieties:Have the child(ren) received counseling?* Yes No Additional Adult Attending Group Sessions (#1) First Last Please include spouses, grandparents or other adult support members that would like to attend group sessions. Additional Adults Attending Group Sessions (#2) First Last Please include spouses, grandparents or other adult support members that would like to attend group sessions. Additional Adults Attending Group Sessions (#3) First Last Please include spouses, grandparents or other adult support members that would like to attend group sessions. Additional Infomation.Please provide any information you feel would be beneficial for facilitators to know.How did you hear about The Kid's Place Grief Support Groups?* Newspaper Counselor School Counselor Social Worker Church Friend
