C.U.B.S. Program Registration Form

Parent/Guardian’s Name: *

First NameLast Name

Date*

Date

Relationship to Child (ren):*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number: Mobile*

Please enter a valid phone number.

Phone Number: Home

Optional

Phone Number: Work

Optional

Were you or your family a part of the Kaweah Health Hospice program?*

YesNo

How did you hear about the C.U.B.S program?

I understand that my child’s work from the C.U.B.S/ CC Kids program may be used anonymously for the purpose of teaching others about the loss issues of children.

Parent/Legal Guardian who will attend the parent Group: *

Child's Name #1:   Name*   Age:    Age*   Grade:   Grade*
We serve food on the last week of CUBS. Can they participate?   Yes   No*
Please list any food allergies, or enter none:   List Food(s)*

Child's Name #2:   Name   Age:    Age   Grade:   Grade
We serve food on the last week of CUBS. Can they participate?Yes   No
Please list any food allergies, or enter none:   List Food(s)

Child's Name #3:   Name   Age:    Age   Grade:   Grade
We serve food on the last week of CUBS. Can they participate?Yes   No
Please list any food allergies, or enter none:   List Food(s)

Child's Name #4:   Name   Age:    Age   Grade:   Grade
We serve food on the last week of CUBS. Can they participate?Yes   No
Please list any food allergies, or enter none:   List Food(s)

Please share in brief the reason for joining C.U.B.S. (include any special needs)

Name and date of death of the person who died.

Please verify that you are human*