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Grief Support Pre-Registration

Name of Person Completing Form:*
First Last
Relationship to Child(ren):*
Our Family is a . . .*
- New Family (First Time Joining Group)
- Returning Family
- Current Family
Group Selection*
- Virtual
- In Person
- Young Adult
How did you hear about us?*
- School
- Counselor
- Victims Advocate
- Doctor
- Family/Friend
- Past Participant
- Current Participant
- Funeral Home
- Hospice
- Internet Search
When did you enter the Grief Program? (Month/Year)*
Parent/Legal Guardian to Child(ren):*
First Last
Relationship:*
Date Assigned as Legal Guardian (if court appointed):
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
County of Residence:*
- Orange
- Seminole
- Osceola
- Volusia
- Lake
Email: (Please provide an email address that the parent/legal guardian has access to and checks regularly)*
Cell Phone*
Alternative Phone
Permission to text? (Note: Group Reminders/Updates are sent via text)*
- Yes
- No
Do you have access to internet for virtual meetings?*
- Yes
- No
Which of the following do you have for accessing virtual meetings?*
- Desktop Computer
- Laptop Computer
- Tablet
- Cell Phone
- All of the Above
- None of the Above
How many children ages 3-18 will participate?*
How many adults will participate in the adult support group?*

Child 1: Name*
First Last
Untitled*
- Male
- Female
Birth Date*
Month
Day
Year
Current Age*
Child 2: Name*
First Last
Untitled*
- Male
- Female
Birth Date*
Month
Day
Year
Current Age*
Child 3: Name*
First Last
Untitled*
- Male
- Female
Birth Date*
Month
Day
Year
Current Age*
Child 4: Name*
First Last
Untitled*
- Male
- Female
Birth Date*
Month
Day
Year
Current Age*
Child 5: Name*
First Last
Untitled*
- Male
- Female
Birth Date*
Month
Day
Year
Current Age*
Child 6: Name*
First Last
Untitled*
- Male
- Female
Birth Date*
Month
Day
Year
Current Age*

Participating Adult 1:*
First Last
Relationship to Child(ren):*
Participating Adult 2:*
First Last
Relationship to Child(ren):*
Participating Adult 3:*
First Last
Relationship to Child(ren):*

Name loved one who died:*
Relationship to Child(ren):*
Date of Death:*
Is your family grieving multiple deaths?
- Yes
- No
Additional Deaths: (please list name, relationship to child(ren) & date of death)*
Additional Information: Please provide any necessary details (Nature of death, concerns for child(ren), etc.) that would offer insight into your grief experience and to help us better serve your child(ren) and family.*
I give the following person(s) access to information on my child(ren)'s behalf. Please include full names and relationships to child(ren):
*
I understand that prior to being scheduled for a new family orientation, our family is to watch the New Hope for Kids' grief program informational video and to complete the grief support group consent form. Both links will be included in your confirmation email to complete your grief support group registration.
*
I understand that the parent/legal guardian must complete the grief support group consent form, which requires consent from all participating adults, to access New Hope for Kids' grief program services (Only the Parent/Legal Guardian can provide consent for a participating child).

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