OCEANS- A GRIEF AND LOSS PEER SUPPORT PROGRAMME
FOR CHILDREN & YOUNG PEOPLE
Enrolment Form
O
Parent/Guardian’s Name
(the person filling this in)
Child’s Surname
First Name
Date of birth
Age
Gender
M/F
M/F
M/F
M/F
Address:
Postcode:
Email address:
Home phone:
Mobile:
Ethnicity:
Please note any medical condition your child may have that we need to know about: eg
food allergies; asthma; epilepsy:
Is he/she currently on any medication? Y / N What?
Mother/
Guardian: _______________________________ phone:______________________________
[and / or as appropriate]
Father
Guardian/_______________________________ phone:_______________________________
How did you hear about the Oceans programme?
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Referral Y / N
(please attach the referral if there is one)
Please tell us about your child’s or children’s loss:
When did the loss occur?
Mon
Please number in order of preference your choice of days that suit
you for meetings from 4pm to 5pm
Tues
Wed
Thurs
Please tick that you agree to the following:
I understand that any information collected about my child or family circumstances will be
used in a confidential and professional manner: ! Please tick
I undertake to notify the Co-ordinator of any changes of address of phone number; or any change of
circumstances that occurs during the period my child is attending Oceans: ! Please tick
If your child is to be collected by any other person not listed below
it very important to notify the Co-ordinator.
Please complete name and phone number of people you approve to collect your child/ren
Name
Phone
Name
Phone
Name
Phone
I have a Protection Order: Yes/No
Who should we call first in the event of an emergency or in the event of any person not
authorised to collect the child?
Name:
Cell Phone:
I understand and agree to sign my child into each session and also when I collect my child.
If anyone attempts to collect your child who is not listed as an authorised person we will
endeavour to contact you immediately. If you have a Protection Order we will contact the
Police immediately.
Please sign your agreement to the procedures outlined in this Enrolment Form:
Signed:
Date:
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