KALEIDOSCOPE GRIEF CENTER &
Kaleidoscope of Caring Inc
Serving Grieving Children & Families

  
_________________________________________________________________________________     

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Camp Healing Hearts Family Application


 

Family Name, Address, Phone:  (* required)

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

Name (s) of the Deceased with Date of Death


Children Attending:

Name  
Date of Birth   mm/dd/yyyy
Sex Male Female

Children Attending

Name
Date of Birth mm/dd/yyyy
Sex Male Female

Children Attending:

Name
Date of Birth mm/dd/yyyy
Sex Male Female

Adults Attending:

Name  
Date of Birth mm/dd/yyyy
Sex Male Female

Adults Attending:

Name
Date of Birth mm/dd/yyyy
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: 03/04/09


_____________________________________________________________________________________________________________
Kaleidoscope Grief Center
1600 Aldersgate RD Ste 100B Little Rock, AR 722057
Phone: (501) 661-0720 Ext 7170 / Toll Free (877) 357-5437    Fax: (501) 537-2718
To email us click here



Kaleidoscope Resale Boutique (Little Rock's upscale thrift shop)
 
provides support for Kaleidoscope Grief Center's programs and services.
 Located at
3608 Kavanaugh Blvd., Little Rock, AR. 72205
 Call 501-975-6666 for information or email jimgates@kaleidoscopekids.org

 

  https://www.methodistfamily.org
  Methodist Family Health