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Become a Member of Kaleidoscope
To become a member of Kaleidoscope, a parent or guardian can complete the application below. Once your application is received, an intake will be scheduled. After that, the child is placed in an age appropriate group.
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* Indicates required question
Email
*
Your email
Today's Date
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MM
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DD
/
YYYY
Child's information:
Name
*
Your answer
Age
*
Your answer
Date of Birth
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MM
/
DD
/
YYYY
School
*
Your answer
Grade
*
Your answer
Teacher
*
Your answer
Siblings (Names & Ages)
*
Your answer
Educational Needs
*
Your answer
Sports/Hobbies/Activities
*
Your answer
Church affiliation
Your answer
Parent/Guardian information:
Name
*
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
ZIP/Postal Code
*
Your answer
Phone (Cell)
*
Your answer
Phone (Home)
Your answer
Phone (Work)
Your answer
Email
*
Your answer
Place of Employment
*
Your answer
Information about the person who died:
Name
*
Your answer
Age
*
Your answer
Date of Death
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MM
/
DD
/
YYYY
Relationship to Child
*
Your answer
Where the death occurred
*
Your answer
Causes and circumstances of the death
*
Your answer
What other deaths has your child experienced (include dates)
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Your answer
What other changes have you and your child experienced (moved, changed schools, jobs, etc.) since the death
*
Your answer
Photo Release (Minor):
I grant Kaleidoscope permission to take and publish photos in which my child might be included. I understand that these photos may be used for media including print media or distribution over the internet in promotional or editorial content. I understand that the use of such photographs will never be accompanied by my child’s name, age, school, or any other information which might be used to identify my child. I understand that my agreement to these terms is voluntary and I agree to immediately raise any concerns or areas of discomfort my child or I might have about being photographed with Kaleidoscope volunteers. Please sign below to indicate that you have read and you understand this information and that any questions you might have about our use of photography have been answered.
*
Yes
No
Name of Parent or Guardian
*
Your answer
A copy of your responses will be emailed to the address you provided.
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