Registration for Rainbows community program September 2020
Christ Community church building on 2221 Bowen Road, Nanaimo
Grief Peer support group program for kids ages 4 and up. Parent group only for parents of kids participating
Registration filled not a guarantee of getting into program. You will receive conformation when registration information has been received by the program coordinator.
Email address *
Choose preferred date (please know this may change before September) *
Last name of participant *
Your answer
First (and middle - optional) Name *
Your answer
Birthdate - (required for children only, not parents)
MM
/
DD
/
YYYY
Full Name(s) of Parent(s) - Guardian(s) *
Your answer
Contact information - email and preferred phone number *
Your answer
Reason for wanting to attend Rainbows *
Your answer
Type of loss - Death, Divorce, Separation, Incarceration, Mental Illness etc. *
Your answer
Food allergies and Name of GP (doctor) *
Your answer
Any siblings in the family? (e.g. brother, age 5 - not registered in Rainbows) *
Your answer
Name of school attending *
Your answer
Ability to participate in small group and promise confidentiality *
Emergency contact (someone besides you)- Full Name, relationship to child, phone number *
Your answer
Anyone not allowed in the building during program, relationship to child and full name. *
Your answer
We may have access to a therapy dog, who attends one group during the program (we always have multiple groups). Please let us know if you are ok with this. Some children are scared or have allergies *
Please let us know if you would like to be contacted if you have any concerns or questions
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