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An evening
for teens who have had
someone die
THURSDAY, March 26, 2015
5:30 pm – 8:00 pm (food provided)
Sponsored by:
and
Hospice of Alamance-Caswell
914 Chapel Hill Road, Burlington, NC
REGISTRATION IS REQUIRED!
Please call the KIDSPATH office at 336-532-0123 or email
patti@hospiceac.org or return the registration form on
the back of this flyer to the address above
TEEN RETREAT WORKSHOP
CONSENT FORM
I give permission for my teen, _______________________________________ to participate in
the Teen Retreat Workshop. I give Hospice of Alamance Caswell/KidsPath permission to
provide medical care and to transport my child to the nearest medical facility in case of
emergency. I understand that Hospice of Alamance Caswell/KidsPath may not be held liable in
case of personal accident and/or injury, or of property loss or damage.
Parent/Guardian Signature ______________________________ Date _____________
CONSENT TO PHOTOGRAPH
I, _______________________________, authorize Hospice of Alamance Caswell/KidsPath to
take and use photographs of my teen and of my teen’s artwork, for the purpose of promoting the
services of the agency or for educational purposes.
Teen’s Name: __________________________________________ Age/Grade ____________
Parent/Guardian Signature: ____________________________________ Date _____________
I, __________________________________, hereby authorize Hospice of Alamance Caswell/
KidsPath to take and use photographs of me and my artwork, for the purpose of
promoting the services of the agency or for educational purposes.
Teen’s Signature: ___________________________________________ Date _____________
PICK-UP INFORMATION
Name of person who will pick up my teen:________________________________________
Person and Phone number to call if driver is late:__________________________________
My teen has a driver’s license and will be driving him or herself______(check if yes)
Parent/Guardian Signature:____________________________________________________
IN CASE OF EMERGENCY, STAFF SHOULD NOTIFY:
Name _____________________________________ Relationship _____________________
Address _________________________________________ Phone _____________________
_________________________________________ Other phone/_______________
Primary Physician ________________________________ Phone _____________________
Please mail consent to address on front, email to patti@hospiceac.org, or call 336-532-0123 to register your child
by Friday, February 13.