One Million Monarchs

Which location is most convenient for you?

How many children are you registering?

Name

First Name Last Name

Date of Birth

Month Day Year

Gender

Current medications/allergies

Name

First Name Last Name

Date of Birth

Month Day Year

Gender

Current medications/allergies

Name

First Name Last Name

Date of Birth

Month Day Year

Gender

Current medications/allergies

Name

First Name Last Name

Date of Birth

Month Day Year

Gender

Current medications/allergies

Do you/your children have any special needs that we should be aware of? If so, please explain:

How many adults are living with the child(ren)?

Name

First Name Last Name

Date of Birth

Month Day Year

Relationship to the Child(ren)

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

County

Email

example@example.com

Home Phone

Please enter a valid phone number.

Cell Phone

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Work Phone

Please enter a valid phone number.

Preferred Phone Number

Name

First Name Last Name

Date of Birth

Month Day Year

Relationship to the Child(ren)

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

County

Email

example@example.com

Home Phone

Please enter a valid phone number.

Cell Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Preferred Phone Number

If children are not living with joint custodial parent, please list their information:

Name

First Name Last Name

Relationship to child(ren)

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone

Please enter a valid phone number.

Emergency Information
(Someone other than the custodial parent)

Emergency Contact's Name

First Name Last Name

Phone Number

Race

If Multi-Racial, please specify

Religion

Child's parents are/were

If divorced/separated, how long?

Family's gross annual household income

Were parents living together at the time of death?

Yes No

Name

First Name Last Name

Date of Birth

Month Day Year

Date of Death

Month Day Year

This death was

Sudden Unexpected

Cause of Death

Additional information about cause of death

If prolonged illness, indicate length

Relationship of deceased to child(ren)

If other, please specify

Was/were the child/children living with this person at the time of death?

Yes No

If not, how long has it been since the child/children last saw this person?

Relationship between child/children and the deceased before the death, in your opinion

Has/have the child/children been told everything about the death?

Yes No

Additional info

Was/were the child/children involved in the funeral and burial?

Yes No

Additional info

Please list any changes with have occurred for the child(ren) since the death of this person

Moved to new home Changed schools Changed room child sleeps in Parent has new job Family's finances have suffered Parent has new relationship or remarriage Behavior changes (specify below)

Specify additional information

What, if any, counseling or peer support has your child(ren) received?

How did you hear about One Million Monarchs?

Name of person referring

Please use this space to share any concerns or additional information you want One Million Monarchs to know about your child/children

I understand that One Million Monarchs offers peer support to my family. My family and I are here to share our experiences of death with others who have experienced a death. I understand that One Million Monarchs support groups are not counseling, and do not offer therapy, counseling, assessments or evaluations.

You should not participate in group support services other than on a voluntary basis. You have the right to withdraw from the group at any time. We ask that you inform the group facilitator if you no longer plan to attend the group.

By signing below I hereby release and discharge One Million Monarchs, its officers, employees, volunteers, agents and assigns (the “Released Parties”) from any and all claims which may arise from any cause whatsoever in connection with my participation in these group support services. I further release the Released Parties from any liability for any accident, illness, injury, death, loss or damage to personal property, or any other consequences arising or resulting directly or indirectly from my participation in the group support services. I acknowledge the Released Parties assume no responsibility for any liability, damage, injury or death that may be caused by my negligent or intentional acts or omissions committed prior to, during, or after participation in the group support services, or for any liability, damage, injury or death caused by the intentional or negligent acts or omissions of others. I agree to indemnify, defend, and hold harmless the Released Parties from any injury, loss or liability including reasonable attorneys’ fees and/or any other associated costs, from any action, claim, or demand in connection with my participation in the group support services.

I also agree to ensure that my family conforms to all health and safety precautions as it relates to the Covid-19 pandemic. This includes agreeing to wear a face mask while on site as well as to abstain from attending group if you or your family exhibits any symptoms of the virus or has been in close prolonged contact with a person who has tested positive for Covid-19. I agree to allow One Million Monarchs to conduct a temperature check and visual assessment to ensure that I am in good health prior to attending group. A temperature exceeding 99.9 gives One Million Monarchs reasonable cause to ask a participant to abstain from attending group that week.

Your Email Address *

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Signature *

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Date *

Date

Email

example@example.com

Support Group Intake Questionnaire

Support Group Location

Family Information

Child 1

Child 2

Child 3

Child 4

Adults living with child(ren)

Adult 1

Adult 2

Demographics

Questions about the person who died