HEARTplay 2019-2020 Registration Form
Thank you for your interest in the HEARTplay program. HEARTplay℠, is an award-winning, free program that uses the creative arts to help children, teens, and young adults cope with the death of someone close to them.

Registration is required for participation. This registration form is for the 2019-2020 School Year. If you are a new participant(s), once you have registered we will contact you to set up an intake interview before you attend your first group.

While participants are encouraged, they are not required to attend every meeting of their group.

If you have any questions please contact Jennifer Wiles, MA, LMHC, BC-DMT, HEARTplay Director, Director of Children's Services, CareGroup Parmenter Home Care & Hospice, Inc. Call or text: 508-309-5107 Email: jwiles@mah.harvard.edu

Mt. Auburn Hospital/HEARTplay welcomes all members of our community regardless of age, ancestry, color, disability, gender, gender identity or expression, genetic information, handicap, military service, national origin, race, religion, sex, or sexual orientation or source of payment for your care.
Participant's First Name *
Your answer
Participant's Last Name *
Your answer
Participant's Date of Birth *
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DD
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YYYY
Participant's Sex
Ex: female, male, MtF female, FtM male, intersex, non-binary
Your answer
Participant's Preferred Pronouns
Participant's Email Address *
Please include parent/guardian email addresses for younger participants and those who want to receive HEARTplay information via email.
Your answer
Participant's Phone Number *
For older participants who have their own phone/phone number
Your answer
Please confirm participant's phone number. *
Your answer
Parent or Legal Guardian's First Name *
Your answer
Parent or Legal Guardian's Last Name *
Your answer
Parent/Legal Guardian's Email Address *
Your answer
Please confirm email address. *
Please include the most appropriate email address(es) to receive HEARTplay emails.
Your answer
What is your relationship to the participant? *
If you choose 'other' please explain.
Parent/Legal Guardian's Preferred Phone Number *
Your answer
Participant's Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Please select which HEART play group participant is interested in. *
Participant would like to be a HEARTplay Mentor (must be age 13 or older).
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