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 *
Today's Date *
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Child's information:
Name *
Age *
Date of Birth *
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School *
Grade *
Teacher *
Siblings (Names & Ages) *
Educational Needs *
Sports/Hobbies/Activities *
Church affiliation
Parent/Guardian information:
Name *
Address *
City *
State *
ZIP/Postal Code *
Phone (Cell) *
Phone (Home)
Phone (Work)
Email *
Place of Employment *
Information about the person who died:
Name *
Age *
Date of Death *
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Relationship to Child *
Where the death occurred *
Causes and circumstances of the death *
What other deaths has your child experienced (include dates) *
What other changes have you and your child experienced (moved, changed schools, jobs, etc.) since the death *
A copy of your responses will be emailed to the address you provided.
Submit
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