Healthy Grieving Program Application

I declare that the information provided by me on this application is true and accurate to the best of my knowledge and belief. I understand that misrepresentation or incorrect information provided may result in refusal of application or revocation of acceptance.*
- I understand and agree with the above statement and will complete this application according to these terms and conditions.
Title
Name*
First Name Last Name
Relationship to Camper*
Other Relation
Address*
Street Address Suburb State Post Code Country
Mobile*
Phone
Email*
Emergency Contact Details
Name*
First Last
Emergency contact Relationship to Camper*
Other type Relationship for Emergency Contact
Emergency Contact Primary Contact Number*
Emergency Contact Secondary Contact Number*
Emergency Contact Email*
Family Doctors Information
Doctor's Name*
Doctor's Contact Number*
Consent to contact Doctor*
From time to time our Head Psychologist may need to consult with your child's Doctor.
Bereavement History
Name of deceased*
Relationship to camper (s)
Other relation
Where did they work?*
What position did they hold?*
What date did the death occur
DD slash MM slash YYYY
Cause of death
Cause of death other
Does your child know that their loved one died by suicide?
Where did this person die
Additional details surrounding death
Has the family received counselling?*
Has the family received counselling? (If yes, please elaborate)

Emergency Contact Details