Journeys Child

For ofc use:

Date_________________

C/H__________________

AT___________________
Center for Children Application
Today's Date

Month Day Year
Child/Teen's name:

First Name Last Name
Nickname:
Gender
Age:
month
Birth Date

Month Day Year
School grade:
School Attending:
Guidance Counselor:
Parent(s) / Legal Guardian:

First Name Last Name
Mailing Address

Street Address

Street Address Line 2

City Postal/Zip Code

County State/Province
Home phone:

Area Code Phone Number
Work phone:

Area Code Phone Number
Cell phone:

Area Code Phone Number
Parent email address
Loved one's name *

First Name Last Name
Relationship to child/teen: *
What is the illness or what was the cause of death? *
Date of death (if occurred):

Month Day Year
Date
Explain the circumstances of the illness or death: *
What has the child/teen been told about the illness or death? *
What spiritual beliefs has the child/teen been taught about death? *
Please list any concerns (problems with medical health, eating, allergies, physical limitations, sleep, relationships, school, other major changes, etc.): *
How did you hear about the Center for Children program?

Hospice of the Piedmont Staff Hospice of the Piedmont Website Newspaper; specify below Hospice of the Piedmont Mailing; specify below Other; specify below
Specify how you heard about the Center for Children program:
To the best of my knoweldge, I verify that the above information is complete and accurate.
Type your name as your signature verifying the above.
Parent/Guardian signature
Today's date

Month Day Year

CENTER FOR CHILDREN INDEMNIFICATION AGREEMENT
By checking I agree and submitting this form, you give permission for your child/teen to participate in the Center for Children program, which includes, but is not limited to groups at school, community locations, or Hospice of the Piedmont offices, individual support sessions, and camps.
PARTICIPATION AGREEMENT *

I Agree
I agree/do not agree to give permission to Hospice of the Piedmont's counselor(s) to share information via telephone, email, or in person regarding my child with his or her counselor and for my child to be seen by a Hospice of the Piedmont counselor, individually, or in a group at school.
COUNSELING AGREEMENT

I Agree I Do Not Agree
Telemental Health Services Agreement

I consent to the below, if applicable.
I hereby consent to engaging in grief related telemental health counseling via Skype or Zoom. I understand that telemental health counseling may include the practice of grief support, consultation, and education using interactive audio, video, or data communications.

I understand the following with respect to Telemental health services:
- I understand that there are risks and consequences from distance counseling, including, but not limited to, the possibility, that despite reasonable efforts on the part of my child’s counselor, that: the transmission of confidential information could be disrupted or distorted by technical failures. These risks are offset by my child’s bereavement counselor’s use of Skype for Business or Zoom, HIPPA-compliant services which are encrypted for video telemental health communications. Further, the contents of my child’s therapist’s computer are encrypted.
- In addition, I understand that telemental health services and care may not yield the same results nor be as effective as face to-face service.
- In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means, including telephone or secure email. I understand that SMS text messaging (e.g., through my cellular provider) and nonencrypted email are not secure and should not be used to convey confidential information.
- It is my responsibility to maintain privacy on the client end of communication. This includes not recording telemental health consultations without discussing the risks with my child’s counselor.
- I understand that there are potential risks and benefits associated with any form of counseling, and that despite my child’s efforts and the efforts of my child’s counselor, my child’s condition may not improve and in some cases may even get worse. I understand that my child may benefit from distance counseling, but that results cannot be guaranteed or assured.
- I acknowledge, however, that if my child may be facing an emergency situation that could result in harm to them or to another person; I am not to seek a telemental consultation for my child. Instead, I agree to seek care for my child immediately through our own local health care counselor or at the nearest hospital emergency department or by calling 911.
I agree/do not agree to give permission for my child/teen to be photographed, videotaped, or interviewed and for his/her artwork to be photographer during the Center for Children program under supervision of staff. This material may be used for future publicity of the Center for Children program, including news media.
PHOTOGRAPHY AGREEMENT *

I Agree I Do Not Agree
In consideration of the above-named child/teen being accepted by Hospice of the Piedmont to attend the Center for Children program:

I, for myself and on behalf of my child/teen, release and discharge Hospcie of the Piedmont, its staff, Board of Directors, Officers, Volunteers, from all claims, demands, actions and judgments, which I or my child/teen ever had or now has or may have against Hospice of the Piedmont for all personal injuries, either physical or emotional, known or unknown, and injury to property, real or personal, sustained by my child/teen's person or property during his or her participation in Center for Children camps or activities, including but not limited to, injury caused by negligence.

I agree to indemnify and hold harmless Hospice of the Piedmont, for any and all claims, demand, actions and judgments whatsoever of every name and nature, both in law and equity, which my child/teen ever had or now has or may have against Hospice of the Piedmont for all personal injuries, either physical or emotional, known or unknown, and injury to property, real or personal, sustained by my child/teen’s person or property during his or her attendance at Center for Children camps or activities, including but not limited to, injury caused by negligence.

I, the undersigned, have read this release and understand all of its items. I understand that this content is valid for one (1) year from date of agreement, or the date my child ends his/her involvement with the Center for Children programs described herein, whichever is later.
RELEASE: *

I Agree to Statement of Release
Enter the message as it's shown *

For Participation in Journeys Spring or Fall Camps, Please Complete the Following:
Last Tetanus shot:

Month Day Year
Are immunizations up-to-date?
T-shirt size:
Dietary Restrictions:
Medications:
Are there any activities your child/teen may not be able to participate in?
If yes, please explain:
Physician's name:

First Name Last Name
Phone Number

Area Code Phone Number
Hospital of Choice:
Emergency contact #1:

First Name Last Name
Relationship:
E-mail address:
Home phone:

Area Code Phone Number
Cell phone:

Area Code Phone Number
Work phone:

Area Code Phone Number
Emergency contact #2:

First Name Last Name
Relationship:
E-mail address:
Home phone:

Area Code Phone Number
Work phone:

Area Code Phone Number
Cell phone:

Area Code Phone Number
TERMS AND CONDITIONS: I give permission to staff of the Center for Children program to administer first aid to my child and authorize emergency transport to the nearest acute care facility.
I ACCEPT *

By checking this box, you agree to the terms and conditions listed above.
Do you need assistance with transportation to group or camp?

Yes No
If yes, please sign below.
I give permission for the Center for Children programs staff, volunteers, and (as applicable) public transportation services to transport my child/teen to/from Center for Children activities and events.
Signature of parent/guardian
Date
Should be Empty:

Center for Children Application

CENTER FOR CHILDREN INDEMNIFICATION AGREEMENT

For Participation in Journeys Spring or Fall Camps, Please Complete the Following: