BLUE Group Inquiry Form

Please fill out this form and click submit.

If you are the parent or caregiver of a child/youth who has experienced a death, we'd be honored to serve your family. Please submit the following information to get connected with WonderSpace BLUE Peer Support Groups. Groups are held every other Tuesday evening at College Wesleyan Church from 5-7pm. A family dinner is provided.

Parent/Caregiver Name

This address will receive a confirmation email

Phone

Address

Child/Youth Name

Birthdate of Child/Youth

School Attending

Please select one option.

Eastbrook Homeschool Madison Grant Marion Mississinewa Oak Hill Private Other

Grade Level

Please select one option.

PreSchool Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Other

Child/Youth Name

Birthdate of Child/Youth

School Attending

Please select one option.

Eastbrook Homeschool Madison Grant Marion Mississinewa Oak Hill Private Other

Grade Level

Please select one option.

PreSchool Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Other

Child/Youth Name

Birthdate of Child/Youth

School Attending

Please select one option.

Eastbook Madison Grant Marion Oak Hill Private Other

Grad Level

Please select one option.

PreSchool Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Other

Child/Youth Name

Birthdate of Child/Youth

School Attending

Please select one option.

Eastbrook Madison Grant Marion Mississinewa Oak Hill Private Other

Grade Level

Please select one option.

PreSchool Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Other

WonderSpace BLUE peer grief support groups serve children/youth and their caregivers who have experienced the death of a family member. Please provide the relationship of the person that died (parent, sibling, etc) and a brief description of the manner of death (cancer/illness, accident, suicide, etc)

Date of Death

I understand that WonderSpace BLUE offers peer grief support groups. My family and I are here to share our experiences of death with others who have experienced a death. I understand that the BLUE support groups are not counseling. By submitting this form, I consent to be contacted by BLUE staff to further determine our eligibility and participation options.

Description

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BLUE Group Inquiry Form

Description

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