Jewish House : Register

First Name

Last Name

Email Address

Mobile

Your child's name *

Your child's age and D.O.B *

Attending siblings name

Siblings age and D.O.B

Which school does your child/ren attend? *

Your Address *

Emergency contact information *

Relationship to child *

Does your Child have any diagnosed learning, emotional or behavioural issues? *

Does your child struggle with anxiety.

What other strategies or programs have you tried?

Is there anything else you feel I should know to be able to help your child?

Have you discussed this program with your child and are they willing to come? *

What would you like your child to learn from this workshop?

Will you encourage and help your child to complete their tasks as much as possible keeping in mind it is meant to be a positive experience?

Would you like a telephone consultation before the group starts to discuss your child and their individual needs?

Would you like to attend a short parent session via zoom before the program starts?

Who will usually be dropping off and picking up the child/children? *

I hereby give permission for the above named child/ children to be photographed with their verbal permission. *

Do you give permission for your child to be given a snack as part of the mindful eating session if this is included in your child's class? *

Thank you for taking the time to fill out this form. This allows us to tailor the program to fit each group's and individual's needs.

Please note this program is an accredited and nurturing program, with each week building upon the last. It is essential your child attends each week unless they are sick. If your child misses the first week, they will not be able to attend the program as that first week is a necessary bonding time for the group and helps the children to feel safe together.

We look forward to meeting and working with you and your children.

You will receive an outline of the program after processing this application.

Peaceful Kids