C.H.E.L.A. 4 Kids Support Group Registration

Support Group Registration Form

To apply support group participation the child's parent or guardian must fill and sign this registration form.
Parent / Guardian Name

First Name Last Name
Child Name and Age
Child Name and Age
Child Name and Age
Child Name and Age
Child Name and Age
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail
example@example.com
Home Number
Cellular Number
Work Number
Is there anything you would like to share with the facilitators about your child(ren)?
Signature, by signing you are giving permission for your child that you are the parent or guardian of to participate in a monthly ZOOM Support Group facilitated by licensed teachers, counselors and therapists. This support group does not disclose that it is designed for children of incarcerated parents or at risk youth. The groups are designed to have an outlet for the children to share, learn, exchange and have FUN! In addition you are giving permission to C.H.E.L.A. 4 Kids to own the full rights of the support group videos. Videos will not be shared publically.

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Signature Date

Month Day Year
Date
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Support Group Registration Form