Beagle MS - Ele's Group Permission Form

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I consent to my child’s participation in a grief support group as described in the email from the school counselor / social worker. I am aware that the following will occur as part of my child's participation in this program:

1. My child will take part in weekly group meetings where we will discuss the grieving process, feelings related to the death, memories, and coping skills.

2. This group will meet during the school day for 8 weeks for one class period per week. Group members are expected to arrive by the start of the group and stay for the entire group session.

3. My child is responsible for all class work and homework missed as a result of their participation in the group.

4. My child will complete a questionnaire about their experience in Ele’s Group.

5. Ele’s Place will send a letter home about the topics covered after the group is completed.

6. Students’ personal information will be kept in strict confidence.

7. My child’s participation in Ele’s Group is voluntary and they are free to withdraw from the program at any time.

8. My child will not attend Ele's Group if they are experiencing any of the following symptoms: cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.

9. My child will comply with all COVID safety measures asked of them by Ele’s Place staff and their school including: wearing a mask, distancing from other group participants, using hand sanitizer, and cleaning/disinfecting work areas.

10. In the event that the school transitions to virtual instruction, the school partner will contact you regarding closure of the group.

By completing the survey below, I agree to the terms and conditions (as outlined above) for my child to participate in an Ele’s Group through their school.

Child's First Name *

Child's Last Name *

What best describes the child's gender? (To self-identify, please click on "other" and type in your answer) *

Female

Male

Non-binary

Prefer not to answer

Other:

Child's Race

African American or Black

Asian or Asian American

White

Hispanic, Latino, Latina, or Latinx

American Indian or Alaska Native

Multi-Racial

Other:

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What was the relationship of the person who died to this child? *

Parent

Sibling

Friend

Grandparent

Other:

What was the cause of death? *

Accident

Suicide

Homicide

Other Sudden Death

Illness

Other:

If your child experienced more than one death, please indicate your child's relationship to the person/people who died and cause of death(s):

Name of Parent/Guardian (A parent or legal guardian must physically or verbally complete this permission form). *

Home Address *

Parent's Phone Number *

Parent's Email Address *

Emergency Contact Person *

Emergency Contact Phone Number *

This survey was filled out by: *

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