Staying Connected A Workshop for Children and Youth Who Have Had a Parent Die Saturday, May 2, 2015 10:00am TO 1:00pm (Lunch Will Be Provided) To Be Held at the Hospice Office and Counseling Center 914 Chapel Hill Road Burlington, NC To register, please complete the registration on the reverse side and mail to: KidsPath Registration 914 Chapel Hill Road, Burlington, NC 27215 For more details, call Patti at 336 336--532 532--0123, or email [email protected]. Hospice of Alamance-Caswell/Kids Path WORKSHOP CONSENT FORM FOR CHILDREN AND TEENS I give permission for _______________________________________ to participate in _____________________________ workshop. I give Hospice of Alamance Caswell/KidsPath permission to provide medical care and to transport my child to the nearest medical facility in case of emergency. I understand that Hospice of Alamance Caswell/KidsPath may not be held liable in case of personal accident and/or injury, or of property loss or damage. Parent/Guardian signature ______________________________ Date _____________ CONSENT TO PHOTOGRAPH I, _______________________________, hereby authorize Hospice of Alamance Caswell/ KidsPath to take and use photographs of my child and of my child’s artwork, for the purpose of promoting the services of the agency or for educational purposes. I relieve and agree to hold Hospice of Alamance Caswell/KidsPath free and harmless from any and all liability arising out of photographs and subsequent publications. Child’s Name: ____________________________________ Age/Grade ____________ Child’s Name:_____________________________________ Age/Grade____________ Parent/Guardian signature____________________________ Date _________________ ___________________________________ Staff Representative Signature _____________ Date and Time PICK-UP INFORMATION Name of person who will pick up my child:___________________________________ Phone number to call if driver is late:________________________________________ IN CASE OF EMERGENCY, STAFF SHOULD NOTIFY: Name _____________________________________ Relationship _________________ Address _________________________________________ Phone _________________ Other phone/pager # _________________ Second contact name ______________________________ Phone _________________