HEARTplay 2018 Registration Form
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 2018.
If you completed a Fall 2017 Registration you do not need to register again for 2018.

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

Participant's First Name *
Your answer
Participant's Last Name *
Your answer
Participant's Date of Birth *
MM
/
DD
/
YYYY
Participant's Gender
Your answer
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 *
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
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).
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service