Become a Member of Kaleidoscope
To become a member of Kaleidoscope, a parent or guardian can complete the application below. Once your application is received, an intake will be scheduled. After that, the child is placed in an age appropriate group.
Email address *
Child's information:
Name *
Your answer
Age *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
School *
Your answer
Grade *
Your answer
Teacher *
Your answer
Siblings (Names & Ages) *
Your answer
Educational Needs *
Your answer
Sports/Hobbies/Activities *
Your answer
Church affiliation
Your answer
Parent/Guardian information:
Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
ZIP/Postal Code *
Your answer
Phone (Cell)
Your answer
Phone (Home)
Your answer
Phone (Work)
Your answer
Email *
Your answer
Place of Employment *
Your answer
Information about the person who died:
Name *
Your answer
Age *
Your answer
Date of Death *
MM
/
DD
/
YYYY
Relationship to Child *
Your answer
Where the death occurred *
Your answer
Causes and circumstances of the death *
Your answer
What other deaths has your child experienced (include dates) *
Your answer
What other changes have you and your child experienced (moved, changed schools, jobs, etc.) since the death *
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy