NALAG Centre for Loss & Grief, Dubbo

Please return completed form to the NALAG Centre:

FAX: 02 6884 9100 Email: Mail: PO Box 379, Dubbo NSW 2830

For more information: Phone 02 6882 9222

Seasons for Growth Registration Form

Child’s Information
(please complete a separate form for each child)
Family Name: / Given Name: / Birth date:
/ / / Age: / Sex:
F  M
Street address: / Town: / State / Postcode:

Parent/Guardian’s Information & Consent

Family Name: / Given Names: / Relationship to Child:
Mobile Phone No: / Home Phone No.: / Work Phone No:
PO Box: / Email Address: / Occupation:
In the event of an emergency we will contact the person indicated above. Please provide an alternative should we be unable to contact you:
Name: Contact Phone No: Relationship to Child:
I give permission for my child to photographed for NALAG publicity purposes YES/NO

DECLARATION: I hereby declare that I am the parent/guardian of the child above and I give my consent to their participation in the Seasons for Growth Program conducted by the NALAG Centre for Loss & Grief Dubbo.

Parent/Guardian Signature:______Dated: ______

Statistics
Aboriginal or Torres Strait Islander / Disabled / CALD
(Culturally or Linguistically Disadvantaged)
YES/NO / YES/NO / YES/NO
Health Information
Please list any health conditions (physical, mental and intellectual) that the child may have.
(Please advise us if your child has been diagnosed with ADD, ADHD, ODD, and Asperger’s Syndrome etc. - or has a learning difficulty –reading and writing etc).
Please list any allergies that the child may have.
(We will provide afternoon tea each session and also a celebration meal at the end of the SFG program – please advise of any food allergies peanuts, gluten etc).
Current Situation
Losses:(Please circle)
Death of Mother, Father, Sibling, Grandparent, Divorce, Separation, Disability, Pet, Trauma, Other: (please specify)
Date of Death (if applicable):
/ / / Are there any legal issues?
Please provide us with some background information about the child and why you believe Seasons for Growth would be beneficial.
Office Use Only
Date registration received:
/ / / Registration taken by:TH / SC / GO
Other______/ Registration Accepted:
Yes/No / Seasons Group Start Date / Completed Seasons
Yes/No / Database Updated: / Registration No:
Name Companion/Volunteer assigned:
Notes: / Date: / Initials:

FRM 001 NALAGDOCS:EDUCATION:08 SEASONS FOR GROWTH EDU 011:Seasons 2016:2016 Registration Form SEASONS Version 1 11 FRM 001.docVersion 1.12 – Updated July 2016