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Club Conquer Registration
Club Conquer for Kids & Teens is designed for children aged 8-12 and 13-17, offering a nurturing and secure environment where they can express their feelings and begin to understand the different facets of grief and loss.
Through age-tailored activities and discussions, the group addresses experiences such as the death of a loved one, a family member's deployment, parental incarceration, divorce, or separations due to foster care or adoption. With a focus on fostering connection and understanding, children are encouraged to explore and articulate their emotions through creative projects and interactive storytelling.
Guided by trained facilitators, this group aims to help children feel less alone and fosters a supportive community among peers facing similar challenges.
Child's Name:
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First
Last
Child's Gender:
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Child's Date of Birth:
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Child's Age: AGES 8-17 ONLY
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Child's Ethnicity/Race:
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Please select
Asian or Asian American
Black or African American
Hispanic or Latino
Middle Eastern or North African
Multiracial
White
Prefer not to answer
What grade will your child be completing in May 2025?
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Please Select One
Pre-k
Kindergarten
First
2
3
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5
6
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Parent/Legal Guardian:
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Relationship to Child:
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Parent/Legal Guardian's Phone Number:
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Parent/Legal Guardian's Email:
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Second Emergency Contact:
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Relationship to Child:
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Second Emergency Contact's Phone Number:
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Second Emergency Contact Email:
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Please check off which sessions your child will attend:
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July 3rd
July 10th
July 17th
July 24th
How did you hear about Club Conquer?
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The Hospice of BR Staff
The Retreat Staff
The Hospice of BR Website
The Retreat Website
Social Media
Marketing Event
Word of Mouth
Other
AUTHORIZED PICK UP:
Please list the persons authorized to pick up your child, including yourself. Each authorized person must be at least 16 years old. The child will not be allowed to leave with anyone not listed below. Authorized persons may be required to show identification to The Retreat at Quarters Lake Staff.
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Additional Authorized Person
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Additional Authorized Person
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Additional Authorized Person
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We’d love to hear more about why your child is attending Club Conquer! ? Sharing this information helps us better understand and support their emotional needs without putting them in a position to answer tough questions directly. It also allows us to tailor relevant activities and content for their unique situations.
When you share, please include:
1. The name of the person or pet involved in the loss ?❤️
2. Their relationship to your child ?
3. The circumstances surrounding the loss (e.g., death, incarceration, parental separation due to foster care/adoption, deployment, divorce, anticipating the loss of a loved one, etc.) ?
4. How long ago the loss occurred ⏳
Thank you for helping us create a safe and nurturing environment for your child!?
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Please click on the "Club Conquer Consent Forms" button below to COMPLETE your child's registration.
VIDEO/PHOTOGRAPH RELEASE:
I hereby grant The Retreat at Quarters Lake / The Hospice of Baton Rouge the irrevocable right and permission to use photographs and/or video recordings of me at events such as Club Conquer, Family Day, or other events and other websites and in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose without compensation to me.
I understand and agree that such photographs and/or video recordings of me may be placed on the Internet. I also understand and agree that I may be identified by name and/or title in printed, internet or broadcast information that might accompany the photographs and/or video recordings of me. I waive the right to approve the final product. I agree that all such portraits, pictures, photographs, video and audio recordings, and any reproductions thereof, and all plates, negatives, recording tape and digital files are and shall remain the property of The Retreat at Quarters Lake / The Hospice of Baton Rouge.
I hereby release, acquit and forever discharge the State of Louisiana, The Retreat at Quarters Lake / The Hospice of Baton Rouge, its current and former trustees, agents, officers and employees of the above-named entities from any and all claims, demands, rights, promises, damages and liabilities arising out of or in connection with the use or distribution of said photographs and/or video recordings, including but not limited to any claims for invasion of privacy, appropriation of likeness or defamation.
I hereby warrant that I am eighteen (18) years old or more and competent to contract in my own name or, if I am less than eighteen years old, that my parent or guardian has signed this release form below. This release is binding on me and my heirs, assigns and personal representatives.
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VIDEO/PHOTOGRAPH RELEASE:
Clear
