Clone of '25-'26 Companions on a Journey – Parent/Guardian Consent for Minor to Participate in School-Based Support Group

Thank you for taking the time to carefully read and answer every question! We offer grief support services including programs, groups, and events at no charge to the community. This would not be possible without generous donations and grant funding. As such, some of the information in the following questions being asked will be used for grant purposes. Specifically, many grants require statistics on demographics to track if a population is underrepresented or underserved, which is why we include questions related to it on this form.

Your Name (Person Completing the Form)

First NameLast Name

Relationship to Child

Other

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County

Please indicate the county in which you reside.

Child's Name

First NameLast Name

Food Allergies

Please specify the child's food allergies if applicable.

Gender of Child:

Race of Child:

Child's Birthday

Date

Child's School

Please select the school your child attends.

Child's Grade

Child's Age

Age as of today.

Is this your child’s first time attending a group with COJ?

The person(s) the child is missing (due to death, deportation, incarceration, or separation):

Date of Death

If multiple losses, please list the date of the most recent loss.

Type of Death/Loss

Consent for Child to Participate in Grief Support Group(s), Attend Events, Release and Waiver

Companions on a Journey Grief Support (COJ) is a faith-based social service organization that provides bereavement support and educational services for children, teens, and adults. COJ is a section 501(c)(3) non-profit bereavement support organization. COJ support groups, educational services, crisis response, grief support sessions, and events should not be considered a substitute for mental health therapy. Our facilitated groups involve discussion, sharing, and recognition of different perspectives, and facilitators strive to create an inclusive environment for the purpose of working through grief.

I give my consent for the child (named above) to participate in COJ's Bereavement Groups. All of the information I have provided is true and accurate.

I hereby give the above named child permission to participate in COJ activities and events. With respect to the above granted participation consent(s), I acknowledge that no activity is risk free even though COJ and its agents and employees as the activity coordinator(s) will undertake reasonable care for participants. In addition to the above granted participation consents, without payment or additional consideration, I also grant COJ and its agents, employees, successors and assigns the absolute right and permission to use photographic portraits, pictures, digital images, video and voice recordings of my child, including reproductions regardless of the format, in which my child may be included in whole or part, for any lawful purpose whatsoever, including use in any COJ publication or website. COJ uses media to showcase our work to the community, grants, and generous funders. These materials are intended solely for informational and promotional use and have been carefully prepared without personal and school names to ensure individual privacy.

In consideration of the child’s participation in the COJ activities, on behalf of myself, the above named child and all heirs, assigns and next of kin of myself and the above name child, I release, discharge and agree to indemnify, hold harmless and covenant not to sue COJ, its agents, employees, volunteers, successors and assigns from or for any liability arising as a result of the above granted participation and media consents including participation in any COJ activity or event.

I represent that I am at least eighteen (18) years of age and am fully competent to sign this Consent, Release and Waiver, and that all information I have provided is complete, true and accurate.

Signature of Parent/Guardian or Adult Student

The Adult Student acknowledges in executing this Consent, Release and Waiver they are doing so for themselves as the references to child or minor participant in the forgoing document.

I'm interested in learning more about COJ's Family or Adult Grief Support Programs

By registering with Companions on a Journey to participate in grief support groups, you will be added to our email communications. You may unsubscribe from these communications at any time.

Parent/Guardian Registration, Consent, Release and Waiver for a Minor to Participate in Companions on a Journey's Grief Support Groups