Please fill out the form in its entirety to register for Club Courage session beginning Tuesday, October 12.

Child's Name
Age
Grade
School
Parent/Guardian
Relationship
Address
City
State
Zip
Home phone
Work or Cell phone
Child’s Grief Experience
Death
Divorce
Separation
Other

Other Explained
Are siblings currently attending Club Courage?
Grief Reactions/Behaviors (Please check all that apply):
Anger
Withdrawn
Tearful
Shy
Regression
Nightmares
Lying
ADHD
ADD
Stealing
Depression
Run Away
Harm to Others
Sad
Mentioned Suicide
Refusal Talk
Acts as if Nothing Happend
Sullen
Other  

Other Explained

Additional information about the loss experience
How did you hear about
Club Courage,
formerly Rainbows?
School Counselor Friend Newspaper
Church Past Participant Other
Other Explained:

 

To have an application mailed to you or for more information, please call Hendrick Hospice Care 1.800.622.8516 or 677.8516.
Club Courage is made possible by funding from the Children's Miracle Network.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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