What is your first name?

What is your last name?

What is your relationship to the child who has died?

What is your language preference?

If other, please specify:

Phone number

Preferred Email Address

Additional Email Address (optional)

Mailing Address

Emergency Contact (someone not attending)

Emergency Contact Phone Number

Please specify any relevant medical, developmental, or mental health needs.

Will another caregiver be attending?

Caregiver 2 First Name

Caregiver 2 Last Name

Caregiver 2 Relationship

Caregiver 2 Language Preference

If other, please specify:

Caregiver 2 Phone Number

Caregiver 2 Relevant medical, developmental, or mental health needs

Have you experienced the death of a child?

I am joining this list as the following:

Please indicate if other:

Child's First (or Preferred) Name

Child's Last Name

Gender

Date of Birth

Date of Death

Cause/Circumstance Surrounding the Death

Was this an extended illness?

For how long?

Did your child receive any treatment at Children's Health (not required for grief services)?

Do you have an additional child who died?

Child's First (or Preferred) Name

Child's Last Name

Gender

Date of Birth

Date of Death

Cause/Circumstance Surrounding the Death

Was this an extended illness?

For how long?

Did your child receive any treatment at Children's Health (not required for grief services)?

Does your family include siblings under the age of 18?

Will any siblings under the age of 18 be participating? (Please note that sibling participation is required for Family Support Groups in September and Camp Sol).

Sibling 1 First Name

Sibling 1 Last Name

Sibling 1 Gender

Sibling 1 Birthday

Sibling 1 Relevant medical, developmental, or mental health needs

Is there another sibling attending?

Sibling 2 First Name

Sibling 2 Last Name

Sibling 2 Gender

Sibling 2 Birthday

Sibling 2 Relevant medical, developmental, or mental health needs

Is there another sibling attending?

Sibling 3 First Name

Sibling 3 Last Name

Sibling 3 Gender

Sibling 3 Birthday

Sibling 3 Relevant medical, developmental, or mental health needs

Is there another sibling attending?

Sibling 4 First Name

Sibling 4 Last Name

Sibling 4 Gender

Sibling 4 Birthday

Sibling 4 Relevant medical, developmental, or mental health needs

Is there another sibling attending?

Sibling 5 First Name

Sibling 5 Last Name

Sibling 5 Gender

Sibling 5 Birthday

Sibling 5 Relevant medical, developmental, or mental health needs

Is there another sibling attending?

Sibling 6 First Name

Sibling 6 Last Name

Sibling 6 Gender

Sibling 6 Birthday

Sibling 6 Relevant medical, developmental, or mental health needs

Is there another sibling attending?

Sibling 7 First Name

Sibling 7 Last Name

Sibling 7 Gender

Sibling 7 Birthday

Sibling 7 Relevant medical, developmental, or mental health needs

What grief support have you or your family received (e.g. Camp Sol, Support Groups, counseling, etc.)?

If you are registering more than one person, please describe the type of session you prefer (i.e. group session for family or couple, separate session for each family member, separate sessions for parent and children, etc.).

By signing this box, I am indicating that I have read and understood this consent, and I am voluntarily consenting for me and for my children under the age of 18 who are listed on this form to receive bereavement support services provided by Children's Health.

Bereavement Support Services: Children's Health offers bereavement support services, including grief support as part of the normal grief support process. These support services are offered to individuals or families who may be grieving from a loss. The grief support services may be offered in different settings, including individual sessions and support groups. These services do not include any behavioral or mental health therapy or treatment.

The bereavement support services may be conducted through interactive audio, video or other electronic media, and there are both risks and benefits to receiving services through one of these electronic media. Use of electronic media may be limited or unavailable at times because of technological or equipment failures, incomplete or inaccurate data or distortion of images or other information from electronic transmissions. I acknowledge that the Children's Health and its Bereavement Care staff cannot be held liable for advice, recommendations and/or decisions based on factors not within their control, such as incomplete or inaccurate data provided by you or distortions of images resulting from electronic transmission. I understand precautions are taken to protect the confidentiality of the participant's confidential information from unauthorized disclosure; however, I understand and acknowledge that the security of electronic transmission of data, video images, and audio information cannot be guaranteed and confidentiality may be compromised by illegal or improper tampering.

I consent for my child/children named below and myself to receive bereavement support services provided by Children's Health via in-person sessions or through interactive audio, video, or other electronic media, and understand the nature and extent of the potential risks involved. I understand that the bereavement support services may include discussions of family and work issues, and the health of my child/children and me in individual sessions and support groups. The level of participation in receiving the bereavement support services will be determined by me and my child/children. I understand that my child/children and/or I may stop participation at any time by notifying in writing the Bereavement Care staff. I acknowledge that the Bereavement Care staff have not offered any guarantee and are not responsible for any outcomes from the bereavement support services for my child/children and me.

As a condition of receiving bereavement support services, I understand and agree that my child/children and I are not allowed or permitted to make any type of recording (including audio and/or video) of the bereavement support services.

Confidentiality: I understand that all information obtained while participating in bereavement support services is considered confidential, including any information that I or my child/children may receive in participating in support groups. I understand and agree that my child/children and I are required to keep the information obtained through our participation in support groups or other settings as confidential and shall not discuss or share, in any way, this confidential information with anyone else. I understand it is my responsibility to educate my child /children on their obligations to maintain confidentiality. I understand the Bereavement Care staff are required by law to notify appropriate authorities of any information of abuse, neglect, domestic violence, threat of harm, and communicable diseases.

Text / Voice / Automated Messaging: I authorize Children's Health to send communications by text message, voice, and automated calls to the cell phone number I provide. I acknowledge that message and standard data rates and fees will apply, message frequency rates may vary, full security is not guaranteed over telephone networks, and I will need to protect my phone with a password or PIN to prevent unauthorized access. I understand that text and automated messaging may not be used by me to notify Children's Health of any health care needs. Children's Health Mobile Messaging privacy policy and SMS terms of service are available at https://www.childrens.com/footer/policies-procedures.

Release of Liability: In consideration of my child's / children's and my receipt of bereavement support services, I agree to release and hold harmless Children's Health and its affiliated entities against any and all liabilities, claims, damages, losses, costs, and expenses caused or resulting from any injury, of any type, that my child/children and/ or I may have while participating and/or receiving and/or otherwise connected to bereavement support services.

This Consent applies to my child/children listed on this form. I understand that I may change these designations at any time by notifying Children's Health in writing at the address listed below.

This consent is valid for one year from the date signed unless I revoke it sooner. To revoke the consent, the request needs to be made in writing and sent by email to griefsupport@childrens.com or by mail to the following address: Children's Health, Attention: Director of Spiritual Care Services, 1935 Medical District Dr., Dallas, TX 75235.

I have read and understood this Consent and have had a chance for my questions to be answered. I voluntarily provide my consent.

If a second adult in your family is registering, please have that adult sign here to indicate agreement with the consent above. If that person is not available at this time, please have them go to www.childrens.com/griefsupportform and choose the option "Fill out consent form" to sign the required form.

If there were something that we should know to better serve you or your family, what would it be?

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