CHILL Registration Form
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Email *
Name of child *
Address *
Best Contact Phone number *
Date of birth *
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Child's Gender Identity *
Which Pronouns does your Child use? (e.g She/Her; They/Them; He/Him; Ze/zir/hir) *
Parents/Guardian names *
Parents/Guardian phone numbers *
Parents/Guardian email *
Emergency contact information (Please include name, relationship, and phone number) *
Would you like to mention language, cultural, or identity-based considerations for the Facilitator?
Allergies (please list all or reply 'none') *
Dietary restrictions   *
Does your child have any medical conditions that the group facilitator should be aware of? If yes, please list and describe. *
Does your child have anxiety? *
How does your child do academically?
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How does your child get along with peers? *
Does your child have an I.E.P.? *
Does your child have any communication or language challenges? If yes, please describe.
Has your child been or is your child currently in counseling? If yes, please provide the name of the therapist.
List your child’s three greatest strengths:
List three areas that need improvement for your child:
Briefly describe your child’s interests, hobbies, and/or activities:
What are your goals for this group?
Is there anything else you would like us to know about your child to help us in our work together?
Would you like to schedule a parent feedback session to learn more about how your child interacts with and benefits from the group?
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How did you hear about CFCE? *
Would you like to receive email updates (about monthly) from CFCE?
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