Clone of HCGT Registration

Hudson County Teen Grief Group

Hudson County youth ages 12-17 who have lost a loved one due to substance use are eligible to participate in this group with the Lindsey Meyer Teen Institute. These group meetings will focus on processing grief, connecting with others with similar experiences, and participating in hands on fun coping activities. Registration is required for attendance, registration will close on 10/5.
These group meetings will be hosted in conjunction with the Earl A. Morgan Branch of the Jersey City Public Library. Food will be provided at all events. Transportation will be provided from the library to events in the community and participants will be returned to the library after the event.
- Session 1, Oct 10:
  - 11:00 am clinical session at Jersey City Free Public Library: Earl A. Morgan Branch 1841 John F. Kennedy Blvd, Jersey City, NJ 07305
  - 12:30 pm lunch
  - 1:30 pm American Dream Mall - Nickelodeon Universe
  - 6:00 pm return to the library for pick up
- Session 2, Oct 24:
  - 11:00 am clinical session at Jersey City Free Public Library: Earl A. Morgan Branch 1841 John F. Kennedy Blvd, Jersey City, NJ 07305
    12:30 pm lunch
  - 1:30 pm Community Activity TBD
- Overnight Wellness Retreat Friday, November 6 - Sunday, November 8
  - YMCA Camp Mason (23 Birch Ridge Rd, Hardwick Township, NJ 07825 - transportation provided)
- Session 3, Nov 21:
  - 11:00 am clinical session at Jersey City Free Public Library: Earl A. Morgan Branch 1841 John F. Kennedy Blvd, Jersey City, NJ 07305
  - 12:30 pm lunch
  - 1:30 pm Community Activity TBD
Youth Participant Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Ethnicity
Participant Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Language Spoken (if other than English)

Emergency Contacts

In the event of an emergency, or in the event that the parent/guardian is unable to be reached, please provide two individuals that the LMTI Staff may contact.
Emergency Contact #1

First NameLast Name
Phone Number
555-555-5555
Relationship to the Participant
Emergency Contact #2

First NameLast Name
Phone Number
555-555-5555
Relationship to the Participant
Program Release, Waiver, & Indemnification
A. Consent for Attendance and Participation
This information provided in this form is correct and my child has permission to participate in all activities on 10/11, 10/24, 11/6-11/8, and 11/21. They have permission to utilize provided transportation and attend all programs.

B. Emergency
Should an emergency arise, I understand that I will be notified as soon as possible, and I give permission for the attending medical professional to administer treatment to my child. I understand that I am responsible for payment of any medical treatment via insurance or other means. I will hold harmless the Lindsey Meyer Teen Institute and NCADD Hudson/Partners in Prevention, Hudson County Division of Mental Health & Addiction Services, the Jersey City Public Library.

C.Release, Waiver, and Indemnification
I, the undersigned parent/guardian, do hereby execute this release, waiver, and indemnification and agree to represent as follows: The release of NCADD-Hudson/Partners in Prevention, the Lindsey Meyer Teen Institute and their employees, and agents from any and all liability, loss, damage, costs, claims or causes of action including, but not limited to, all bodily injuries and property damages arising out of the sole negligence or other acts or omissions of NCADD-Hudson/Partners in Prevention, and the Lindsey Meyer Teen Institute I further agree to indemnify and hold harmless the said above from any and all liability, loss, damage costs, or causes of action, including attorney’s fees and witness costs, arising out of the undersigned participation in the Lindsey Meyer Teen Institute (LMTI) events scheduled for the 2026-2027 school year.
Parent/Guardian Name

First NameLast Name
Relationship to Participant
Parent/Guardian Phone Number
555-555-5555
Parent/Guardian Email
example@example.com
Parent/Guardian Signature
Should be Empty:

Hudson County Teen Grief Group

Emergency Contacts

Program Release, Waiver, & Indemnification