KALEIDOSCOPE GRIEF CENTER
                          Serving Children & Families

Camp Healing Hearts Family Application

 

Family Name, Address, Phone:

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail

Name (s) of the Deceased with Date of Death


Children Attending:

Name
Date of Birth
Sex Male Female

Children Attending

Name
Date of Birth
Sex Male Female

Children Attending:

Name
Date of Birth
Sex Male Female

Adults Attending:

Name
Date of Birth
Sex Male Female

Adults Attending:

Name
Date of Birth
Sex Male Female

Relationship of child(ren) to the deceased:

child
grandparent
sibling
other

Adult relationship to the deceased:

spouse
parent
sibling
child
other

Will you need childcare for children under 5 years old?

Yes No

Best time to call:

AM
PM

Emergency Contact:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail

How did you hear of Camp Healing Hearts?


Kaleidoscope Kids/Camp Healing Hearts.
Copyright © 2003 [Kaleidoscope Kids]. All rights reserved.
Revised: 07/28/08

Kaleidoscope Grief Center
1501 North University Ave., Suite 680
Little Rock, AR 72207
Phone: (501) 978-5437 / Toll Free (877) 357-5437    Fax: (501) 537-2718
To email us click here
Volunteers please call: (501) 978-5437
We want and need your help!


Kaleidoscope Resale Boutique

provides financial support for Kaleidoscope Grief Center's programs and services.

Located at 3608 Kavanaugh Blvd., Little Rock, AR. 72205
Call 501-975-6666 for information on how to donate items