Kids’ Haven collects information about our participant families and the death they are grieving. Our work with you and your family is confidential, and all information is private.

All families must complete this form before joining group night. If you prefer to handwrite forms, you may print them out here. When attending your first group night, both the guardian and all participants will also sign the Family Agreement Statement and Privacy Statement. A copy of these statements can be viewed and/or printed here. We will also have paper copies at Group Night.

A member of staff would be happy to assist you in completing these forms. Please email connect@kidshavenlynchburg.org or call 434 845 4072 to set up an appointment.

Contact Information
Your name *
Your name
Are you the child(ren)'s legal guardian? *
Contact Phone Number
Contact Phone Number
Address *
Address
Please include name, birth date, age and gender for each participant.
Questions about the person that died
Birthdate *
Birthdate
Date of death *
Date of death
The person died at: *
Questions about the child(ren) attending:
Is the child(ren) currently receiving counseling or therapy? *
Does the child(ren) have a diagnosis that could impact them in a group setting?
Other
Emergency Contact Person
Emergency Contact Person
Emergency Contact phone number
Emergency Contact phone number