The Garden Family Registration Form

    Adult Caregiver First Name

    Adult Caregiver Last Name

    Street Address

    City

    State

    Zip

    Cell Phone

    Daytime Phone

    Evening Phone

    Email address

    Confirm email address

    Please list each child who will be attending The Garden

    Name of first child:

    Age of first child:

    Gender of first child:

    Birthday of first child:

    Grade of first child:

    Name of first child's school:

    Name of second child:

    Age of second child:

    Gender of second child:

    Birthday of second child:

    Grade of second child:

    Name of second child's school:

    Name of third child:

    Age of third child:

    Gender of third child:

    Birthday of third child:

    Grade of third child:

    Name of third child's school:

    Name of fourth child:

    Age of fourth child:

    Gender of fourth child:

    Birthday of fourth child:

    Grade of fourth child:

    Name of fourth child's school:

    Name of fifth child:

    Age of fifth child:

    Gender of fifth child:

    Birthday of fifth child:

    Grade of fifth child:

    Name of fifth child's school:

    Referral Source. How did you hear about The Garden

    Death History: Please list all significant deaths (family members, friends, pets, etc.) in your child(ren)'s life along with the indicated information.

    Name of first person who died and relationship

    From what causes

    Date of death

    Name of second person who died and relationship

    From what causes

    Date of death

    Name of third person who died and relationship

    From what causes

    Date of death

    Were there any significant changes, traumas, crises, or life events that took place for your child(ren) prior to the death that brings you to The Garde? If yes, please explain.

    Please tell us the story of the death which brought you to The Garden.

    What changes have you noticed in your child(ren) since the most recent death?

    What specific concerns do you have regarding your child(ren)?

    Parent/Guardian Agreement with The Garden

    In order for any of us to do the work of grief, we need to feel safe. For children, this means a consistently trustworthy and predictable place. Parents and caregivers play a crucial role in creating such a place at The Garden, and with this in mind, we ask you to indicate your commitment by signing this agreement.

    SAFETY RULES:

    I agree to attend The Garden consistently in order that my child(ren)/teen can get to know and feel comfortable with the group and that the others in my child(ren)’s/teen’s group can feel safe and comfortable with him/her/them. I understand that I will keep our absences to a minimum and that I will call in advance to let The Garden Director know if we have to miss.

    • I agree to actively participate in family activities with my child(ren)/teen.
    • If we cannot attend The Garden on a particular day, I will call The Garden at 413-727-5749 at least 2 hours ahead of time so that others at The Garden know.
    • I agree to be aware of the safety rules at The Garden as outlined in the children’s/teen contract and to help make sure these are followed. Further, I agree to take my child/teen out of a Garden Sunday if a facilitator informs me that the child/teen has broken the contract more than once in the course of an afternoon.
    • I agree to come to The Garden drug and alcohol-free.
    • I agree to give notice two weeks prior to leaving The Garden so that appropriate goodbyes can be said to other group members.
    • I understand that other family members and friends who do not regularly attend The Garden may not attend as one-time or periodic visitors. This enables the groups to build cohesiveness and trust over time.
    • In order that The Garden kids know The Garden is their safe place, I agree not to date The Garden facilitators.

    SCOPE OF WORK AT THE GARDEN: I understand The Garden is a support program for grieving children/teens and does not constitute therapy or counseling. I know that I can ask for a referral to a therapist at any time. Further, if The Garden staff and/or director believe it to be in my child’s best interest, they will recommend one to me as well.

    CONFIDENTIALITY: I understand that all information shared in the groups is confidential with five exceptions –
    1. Group information is shared in the post-meeting of facilitators in order to provide supervision to the work they are doing with the children/teens.
    2. If any person is a danger to themselves or others, we are required to act on the information. For the children/teens, this means that the Director will contact the parent/guardian to work out a helpful plan.
    3. If there is suspected, current physical or sexual abuse of a child/teen, we are required by law to report it.
    4. If anyone is subpoenaed by a court of law, they are required to comply.
    5. If the Director determines that is in my best interest to consult with another therapist about my own or my child(ren)’s/teens situation, they will do so. In this case, the consulting therapist is required to hold the information strictly confidential as well.

    INFORMATION RELEASE: Periodically, I understand The Garden provides educational programs for other professionals as well as for the public about loss and transition. I give The Garden permission to use my story without releasing my name or other identifying information under following situations (please check one) –
    ___ Under no circumstances do I give my permission to use my/our story
    ___ For purposes of professional education only
    ___ For purposes of public education only
    ___ For purposes of professional and/or public education
    Additionally, The Garden may wish to take photographs of program participants for use in promotional materials (i.e. newsletter, Facebook, brochures, etc.). I give The Garden permission to take pictures of my family without releasing my name or other identifying information under the following situations (please check one) –
    ___ Under no circumstances do I give my permission to take my/our picture.
    ___ For purposes of printed dissemination of promotional materials (newsletter, brochure, etc.)
    ___ For purposes of electronic dissemination of promotional materials (website, Facebook, etc.)
    ___ For purposes of printed and/or electronic dissemination of promotional materials.

    PLEDGE SYSTEM: I understand that The Garden is offered on a donation basis in order to meet the needs of all regardless of their ability to pay. However, since The Garden does rely on individual contributions to meet expenses, I pledge $__________ per child, per month to support the work of The Garden. The direct operating cost of the program per month, per child is $150.00. NOTE: Pledge gifts of any amount to defray these costs are welcome. I understand that pledge contributions to The Garden are tax-deductible.

    NO FAMILY WILL EVER BE DENIED PARTICIPATION BASED UPON AN INABILITY TO OFFER A DONATION. SINCE CHARITABLE DONATIONS MAKE THE PROGRAM POSSIBLE, AT THE TIME OF THE ANNUAL APPEAL AND OTHER FUNDRAISING EVENTS, GARDEN FAMILIES WILL BE ASKED TO PARTICIPATE.

    I ACCEPT

    Today's Date:

    Youth Agreement: My Personal Agreement with The Garden

    WHY HAVE A CONTRACT? Being sad or mad, having a lot of extra energy, feeling nervous, or just keyed up inside…are normal feelings that many people have when somebody they love dies. That’s why at the Garden, we promise to do everything we can to give you a safe place to express these feelings. To make this happen, we need some rules. The purpose of this contract is to make the rules clear and to make sure everyone at the Garden is safe.

    Contract

    1. I promise I will keep what is said at the Garden private and confidential.
    2. I promise I will not hurt anyone intentionally at the Garden with my words (put-downs, name-calling, etc.) or actions (hitting, throwing hard objects, etc.).
    3. I will act in a way that allows the group to work together or find a facilitator to talk to.
    4. I will stay in the building at all times unless I am with a Garden adult.
    5. I know I can use the “I pass” rule anytime and not participate in any discussion or activity I choose. I can ask a facilitator to take me to the person who brought me to the Garden at any time.
    6. If someone hurts me with their words or actions, I will tell them how I feel and say, “Stop and I mean it.” If they don’t stop, I will get a facilitator to help us.
    7. I will stop when a child or adult at the Garden says, “Stop and I mean it.” If I do not stop, I will be breaking a rule and a facilitator or other adult will do a rule break with me.
    8. If I break any of the rules a second time on the same day, a facilitator will get the adult who brought me, and I will sit out for the rest of the group that day. I may return to the closing circle. I can return to the group the next time the Garden meets if the facilitator is sure that I will act in a safe way.
    9. If my anger, energy level, or sadness feels out of control to me or to an adult, I can ask a facilitator to talk to me or take me to a quiet place. If my anger or energy still feels out of control, and either the facilitator or I think I might hurt someone else or myself, the facilitator will take me to the adult who brought me, and I will sit out of the group for the rest of the night.
    I understand these rules and agree to follow them to keep myself and others safe at the Garden.

    I ACCEPT

    Today's Date:

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