Painted Sunflowers Registration Form

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THE SIZE OF THIS GROUP IS LIMITED AND IS AVAILABLE ON A FIRST COME FIRST SERVE BASIS. COMPLETING THIS ONLINE FORM DOES NOT GUARANTEE THAT YOUR CHILD WILL BE ABLE TO PARTICIPATE IN THE PROGRAM. AFTER YOU COMPLETE THE FORM, SOMEONE WILL REACH OUT TO YOU TO PROVIDE CONFIRMATION.

Group Purpose
The purpose of this group is to teach social and emotional skills to students at Robert J Burch Elementary School. This group will utilize the school garden and use mindful art practices to build life skills such as managing friendships, teamwork, perspective talking, emotional intelligence, safety, relationship building, problem solving, conversation skills, turn taking, decoding social situations and resiliency.

Group Facilitator
Ms. Wheatley is the art teacher at Robert J Burch Elementary School and also has a masters degree in professional counseling. In her masters program she created a research based curriculum using art and the garden to assist students in gaining life skills. She also provides professional counseling services to client's at Back on Track Counseling. She is under supervision with Ellie Wood.

Agreement
1. The skills taught in this program build upon each other, therefore this program requires a 8 week commitment. If at any time your child can not attend group, Ms. Wheatley will need to be informed prior to the start of the session. If 2 sessions are missed without prior knowledge the student may not be able to continue with the program.

2. The session ends at 3:45pm. Students must be picked up promptly at 3:45. If students are not picked up on time, they may not be able to continue with the program.

3. If a student becomes a safety issue they may not be able to continue with the program.

Student Name *

Grade *

Teacher *

Parent/Guardian Name *

Parent/Guardian Phone # *

Parent/Guardian Email Address *

Who is authorized to pick up your child? Please include their name and their relationship to the child. ID WILL BE REQUIRED. *

Please answer the following questions about your child. *

Strongly Agree

Agree

Disagree

Strongly Disagree

My child is able to make and maintain a healthy relationship with peers.

My child works well with peers.

My child is able to solve simple problems they face on a daily basis

My child can pick up on social cues.

My child can express their emotions when they become upset.

My child has patient skills and is able to take turns.

My child is able to express themselves by communicating.

My child understands their feelings.

My child works well in group settings

Strongly Agree

Agree

Disagree

Strongly Disagree

My child is able to make and maintain a healthy relationship with peers.

My child works well with peers.

My child is able to solve simple problems they face on a daily basis

My child can pick up on social cues.

My child can express their emotions when they become upset.

My child has patient skills and is able to take turns.

My child is able to express themselves by communicating.

My child understands their feelings.

My child works well in group settings

Is your child currently in counseling/therapy? *

Yes

How would you like to see your child grow from participating in this group? *

Is there anything else that you think would be helpful for the facilitator to know in order to help your child?

If you understand and agree to the conditions above for participating in this group, please type your name here and click submit. *

Submit

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