Lory's Place Group

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Lory's Place Group

If you have a child who has experienced a significant death in his or her life and you would like for your child to participate in the Lory’s Place peer support grief group and if you and your child feel that the Lory's Place peer support grief group would be a beneficial support this school year, please complete the following form.

Email *

Name of Student (Last name, First name) *

Building *

Grade *

Classroom Teacher *

Name of Person Who Died *

Relationship of Person Who Died to Your Student *

Cause of Death *

Date of Death *

YYYY

Caregiver Information (Last Name, First Name) *

Phone Contact *

Preferred Email Contact *

Permission *

I give my permission for my student to participate in the Lory's Place Group.

I understand this group meets once per month around the lunch hour.

My student and I understand that this could impact the lunch recess once a month.

Required

Submit

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