Children's Support Group Registration Child’s Information: Child's Name:* First Last Gender:*MaleFemaleNon BinaryAge:* Date of Birth:* MM slash DD slash YYYY Grade* School:* Child’s Caregiver Information:Parent/ Legal Guardian’s Name:* First Last Phone*Alternative Phone*Email:* Your email will only be used to provide additional information about our support group and other children’s services offered by Covenant Care.Caregiver Mailing Address* Street Address City State / Province / Region ZIP / Postal Code Additional Address Directions (optional) Bereavement Information:Name of Loved One:* First Last How did the child lose this loved one?* Death Anticipatory Death Other Relationship to Child:* When did this death/ loss occur?* Cause of Death?* What was the relationship like between the child and their loved one?* Does child know how their loved one died?* Was the child able to attend the funeral, remembrance ceremony, or celebration of life?* Has the Child received professional grief support since the loss? If yes, from whom?* Have there been additional life changes/ losses since the death (moving, changing schools, divorce)?* Please provide any additional information you feel we need to know about your child and their grief.* CONSENT FOR CHILDREN'S BEREAVEMENT ACTIVITIESName of Participant/Child's Parent or Guardian: First Last Relationship to Child Name of Participant/Child: First Last I am the parent or legal guardian of the Participant/Child (hereinafter, "Participant"). I give permission for Participant to participate in bereavement activities (the "Activities") organized and hosted by Covenant Hospice, Inc. ("Covenant"). I understand the goal of the Activities is to help facilitate the bereavement process of the Participant and to provide support for the Participant in expressing feelings of grief and sadness. I understand, acknowledge and agree: 1. Meetings: The Activities may include in-person group meetings with other participants and/or "virtual" group meetings (i.e., meetings conducted via telephone or video conference) with other participants. Participant or his parent or guardian shall be responsible for providing all equipment necessary for Participant's participation in virtual group meetings, including a computer or other electronic device, internet/cellular connection, etc. 2. Protected Health Information: The information shared by the Participant during the Activities may constitute Protected Health Information ("PHI"). The other participants in the Activities will have access to some or all of the PHI shared by the Participant during the Activities. All participants will be asked to maintain the confidentiality of the information exchanged by other participants during the Activities. Participant agrees that he or she will not share any other participant's PHI or other personal identifying information with others not involved in the Activities. I understand and acknowledge that Covenant cannot and does not guarantee that Participant's PHI will not be shared or disclosed by other participants to others not involved in the Activities. Neither Participant nor his or her parent or guardian may make or cause to be made any audio or video recording of any of the Activities, or any portion thereof. Covenant will maintain the confidentiality of Participant's PHI in accord with all federal and state laws, regulations and rules. There are, however, some circumstances in which Covenant may disclose Participant's PHI to third parties, including but not limited to: • If Covenant discovers information that Participant has been abused, neglected, or exploited; • Covenant determines the Participant is in danger of causing death or injury to him- or herself or another; and/or • If Covenant receives a court order, subpoena, or other legally valid request from a third party. 3. Risks of the Activities: The Activities have potential emotional risks for the Participant. The bereavement process is complex and oftentimes painful for children. I acknowledge that the bereavement process-and the Activities-may cause Participant to express emotions that are new to Participant. I will promptly advise Covenant if I believe that Participant is experiencing emotional or behavioral problems that may impact or effect Participant's involvement in the Activities. I will promptly advise Covenant if I believe that Participant is experiencing emotional or behavioral problems that result from Participant's involvement in the Activities. 4. Release of Liability: In consideration for Covenant's provision of the Activities to Participant, I hereby release, waive and forever discharge Covenant, its parent company, affiliates, directors, officers, employees, representatives, agents, successors and assigns (collectively, "Releasees") from any and all actions, claims, damages, judgments, and demands whatsoever that Participant has or may ever have in the future by reason of any injuries, losses and/or damages caused by, relating to, or arising from the Activities. On behalf of Participant, I hereby release Releasees from any liability whatsoever in connection with the Activities. It is the specific intent and purpose of this paragraph to release, waive and discharge any and all claims and causes of action of any kind or nature related to Participant's participation in the Activities, whether foreseeable, known or unknown, and whether specifically mentioned or not, including, without limitation, all claims or causes of actions related to or arising from Covenant's acts, omissions or negligence. I have read this Consent for Bereavement Activities. I have considered it carefully, asked any questions that I needed to, and understand it. Name of Parent/Guardian:* Location*Please selectCrestview AreaDothan AreaDaphne AreaFort Lauderdale AreaFort Myers/Sarasota AreaFort Walton AreaGainesville/Ocala AreaJacksonville/Daytona Beach AreaMarianna AreaMiami AreaMobile AreaOrlando AreaPanama City AreaPensacola AreaSt. Petersburg/Clearwater AreaTallahassee AreaTampa AreaPalm Beach/Port St. Lucie AreaSignature First Last Date MM slash DD slash YYYY