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Group Therapy Registration
Name of parent/ legal guardian *
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Address *
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Email *
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Phone number/ Alternative phone number *
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Name of Child *
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Gender of child
Child's date of birth *
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Age of child *
Current school *
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Student ID *
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Primary language/ other languages spoken *
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Waiver for photos *
Type of loss *
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Date of session *
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Time of session *
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