Support Options

Cause/Circumstance Surrounding the Death

Please indicate which time your family prefers to attend on May 3. (Please note that changes to this time may only be made by emailing griefsupport@childrens.com before April 23).

As a part of the Remembrance Gathering, we would like to put together a slideshow of pictures representing the children we have come to honor.  These could include pictures of your child or other special memories.  Please limit to no more than 5 pictures.

Photo/Reading of Name Permission Statement 

By registering for this event, I am permitting the Children's Health Bereavement Care Program to read aloud the name of my child to all in person and virtual attendees of the 2026 Remembrance Gathering. This permission may be revoked at any time by calling 214-456-3555 or emailing griefsupport@childrens.com

Family Shirt Sizes

Please check here if you prefer not to receive shirts.

Consent for Bereavement Support Services

By signing this box, I am indicating that I have read and understood this consent, and I am voluntarily consenting 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 me 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 my health in individual sessions and support groups.  The level of participation in receiving the bereavement support services will be determined by me. I understand that 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 me.

As a condition of receiving bereavement support services, I understand and agree that I am 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 may receive in participating in support groups. I understand and agree that I am 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 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 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 I may have while participating and/or receiving and/or otherwise connected to bereavement support services.

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: Manager of Bereavement Care Program,  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.

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: Manager of Bereavement Care Program, 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.

CAMP PARTICIPANT CONSENT AND RELEASE

1. Participant Consent: I consent for Camper, which may be defined as me, my child or a child for whom I have legal responsibility, and whom is named below, to participate in the Children’s Health System of Texas (“Children’s Health”) sponsored camp named below (“Camp”). I understand if more than one Camper is named below, any reference to Camper in this Consent and Release will apply to each named Camper. I understand that risks and dangers may be associated with Camper’s participation at the Camp based on the setting and its environment and the camp related activities, including, but not limited to, swimming, sports and games, archery, hiking, fishing and arts and crafts. I understand that Camper’s participation in Camp activities is entirely voluntary, and at any time, Camper may elect to participate, decline to participate, or limit participation in the camp activity. I understand and acknowledge that it is my responsibility to make sure Camper complies with all Camp rules and protocols, including following all safety instructions. Knowing the risks and hazards associated with Camper attending Camp and participating in Camp activities, I am willingly to assume such risks for Camper.

2. Medical Consent: I consent for Camper to receive medical care and treatment, depending on the Patient's medical needs, that may be provided by physicians, nurses, and other health care providers, employees and volunteers at the Camp. Care and treatment may include laboratory, radiology and other testing; evaluation and routine medical, nursing, psychiatric, psychological, mental / behavioral health / counseling, and other patient care, therapies and procedures. I understand that, even with preventative measures, Camper may be exposed to certain communicable diseases from the Camp setting while receiving medical care and treatment.

3. 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.

4. Release and Indemnity: In consideration of Camper’s participation at Camp, I agree to release and hold harmless Children’s Health and its affiliated entities and subsidiaries and their officers, directors, employees, affiliated medical staff, volunteers, agents, and contractors (collectively, “Released Parties”) against any and all liabilities, claims, damages, losses, costs and expenses caused or resulting from any injury, of any type, that Camper may sustain while participating and/or otherwise connected to the Camp and Camp related activities and services. I further agree to defend, indemnify and hold harmless the Released Parties from any liability, judgment or claim asserted by, through, or on behalf of the undersigned and/or Camper, the estate of Camper, or the wrongful death beneficiaries of Camper arising out of or in any way pertaining Camper’s participation in the Camp. The foregoing obligations to defend, indemnify and hold harmless shall be enforceable without regard to actual or alleged negligence, gross negligence, strict or absolutely liability or other fault of the Released Parties, it being the express intention of the undersigned to indemnify the Released Parties for the consequences of the Released Parties’ own actual or alleged negligence, gross negligence, strict or absolute liability or any other fault. This provision shall remain in effect after the Consent has expired.

5. Duration of Consent: This Consent is valid for one year from the date of signed, unless revoked sooner. To revoke the Consent, the request needs to be made in writing and sent by email to TherapeuticCamps@childrens.com or by mail to the following address: Children’s Health, Attention: Therapeutic Camps, 1935 Medical District Dr., MailStop CL -240, Dallas, TX 75235.

I HAVE READ AND UNDERSTOOD THIS CONSENT AND RELEASE AND VOLUNTARILY PROVIDE MY CONSENT.

CONSENTIMIENTO Y EXONERACIÓN PARA LOS ASISTENTES AL CAMPAMENTO

1.Consentimiento del participante: Doy mi consentimiento para que el Campista, que podría seryo, mi hijo u otro menor bajo mi tutela (y cuyo nombre aparece más abajo), asista al campamentopatrocinado por Children’s Health System of Texas (“Children’s Health”) y mencionado a continuación (“elCampamento”). Entiendo que, si aparece el nombre de más de un campista en este formulario deconsentimiento y exoneración, cualquier mención del Campista se refiere a todos ellos. Entiendo que laasistencia del Campista al Campamento implica ciertos riesgos propios del lugar, el entorno y lasactividades que ahí se realizan, como natación, deporte, juegos, tiro con arco, caminatas, pesca ymanualidades. Entiendo que la participación en las actividades del Campamento es totalmente voluntaria yque el Campista puede decidir si va a participar o no en ellas y hasta qué grado participará. Entiendo yreconozco que es mi responsabilidad asegurarme de que el Campista cumpla todas las normas delCampamento, incluidas las de seguridad. Entiendo los riesgos que implica participar en las actividades delCampamento y estoy dispuesto a asumirlos en nombre del Campista.

2.Consentimiento médico: Doy mi consentimiento para que el Campista reciba la atención médicaque necesite, la cual podría ser administrada por doctores, enfermeras y otros profesionales de la salud, asícomo por el personal y los voluntarios del Campamento y podría consistir en análisis, pruebas radiológicasy de otro tipo, así como evaluaciones, terapias y procedimientos de rutina, ya sean médicos, psiquiátricos,psicológicos, mentales o de enfermería, salud mental y consejería. Entiendo que incluso con medidaspreventivas, el Campista podría quedar expuesto a enfermedades contagiosas al recibir atención médica enel Campamento.

3.Llamadas, mensajes de texto y grabaciones de voz: Autorizo a Children's Health a enviarnotificaciones al número que di, ya sean llamadas o mensajes de texto. Entiendo que podría haber cargospor los mensajes, que la frecuencia de los mensajes varía, que no se puede garantizar plena seguridad alusar las redes telefónicas y que debo proteger mi teléfono con una contraseña o un PIN para evitar quepersonas no autorizadas usen mi teléfono. Entiendo que no puedo informar ninguna necesidad médica aChildren’s Health mediante mensajes de texto. La norma de protección de datos de Children's Health, asícomo los términos de servicio sobre mensajes de texto están disponibles enhttps://es.childrens.com/footer/policies-procedures.

4.Exoneración e indemnización: En reconocimiento de que el Campista participará en elCampamento, eximo a Children’s Health, sus entidades afiliadas y subsidiarias, sus directivos,representantes, personal, voluntarios, agentes y contratistas (en conjunto llamados “Partes exoneradas”), decualquier responsabilidad, reclamo, daño, pérdida, costo o gasto que se derive de cualquier lesión, sinimportar el tipo, que sufra el Campista al participar en las actividades y recibir los servicios delCampamento. Además, estoy de acuerdo en defender, indemnizar y eximir de responsabilidad a las Partesexoneradas de cualquier responsabilidad, juicio o reclamo presentado por, a través o en nombre del abajofirmante o el campista, el patrimonio del campista o los beneficiarios de muerte por negligencia delcampista que surja o se relacione de alguna manera con su participación en el Campamento. Lasobligaciones anteriores de defender, indemnizar y eximir de responsabilidad no desaparecen aun cuandoexista o se alegue que haya habido negligencia, leve o grave, con o sin responsabilidad de parte de las Partesexoneradas. La intención expresa de la persona que firma este documento es asumir la responsabilidad yproteger a las Partes exoneradas incluso cuando las consecuencias se deriven de la negligencia, real o
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presunta, leve o grave, sea o no responsabilidad de las Partes exoneradas. Esta disposición permanecerá vigente aún después de que venza el presente Consentimiento.

5.Vigencia del consentimiento: Este consentimiento es válido durante un año a partir de la fecha enque sea firmado, a menos que el firmante lo revoque antes. Para revocar el presente Consentimiento, hayque enviar una solicitud por escrito al siguiente correo electrónico: griefsupport@childrens.com o porcorreo postal a la siguiente dirección: Children’s Health, Attention: Therapeutic Camps, 1935 MedicalDistrict Dr., MailStop CL -240, Dallas, TX 75235.

HE LEÍDO Y ENTENDIDO EL PRESENTE FORMULARIO DE CONSENTIMIENTO Y EXONERACIÓN Y DOY MI CONSENTIMIENTO VOLUNTARIAMENTE.