HEARTplay 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 2021-2022 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, Beth Israel Lahey Health at Home. Call or text: 508-309-5107 Email: jwiles@mah.harvard.edu.
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.

last updated: 10/20/21
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Participant's First Name *
Participant's Last Name *
Participant's Date of Birth *
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/
DD
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Participant's Sex *
Ex: female, male, MtF female, FtM male, intersex, non-binary
Participant's Preferred Pronouns *
Required
Participant's Email Address *
Please include parent/guardian email addresses for younger participants and those who want to receive HEARTplay information via email.
Participant's Phone Number *
For older participants who have their own phone/phone number
Please confirm participant's phone number. *
Parent or Legal Guardian's First Name *
Parent or Legal Guardian's Last Name *
Email Address *
Please include the most appropriate email address(es) to receive HEARTplay emails.
Please confirm email address. *
Please include the most appropriate email address(es) to receive HEARTplay emails.
What is your relationship to the participant? *
If you choose 'other' please explain.
Parent/Legal Guardian's Preferred Phone Number *
Participants 18+ can choose to include their own phone number.
Participant's Street Address *
City *
State *
Zip Code *
Please select which HEART play program the participant is interested in. *
You may choose more than one. We will work with you to find the best fit. All programs are currently virtual.
Required
Participant would like to be a HEARTplay Mentor (must be age 13 or older). *
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