Family Support Registration | Green Heart Inc.

Caregiver registration

Fields marked required help us confirm the request, prepare the kit, and deliver it correctly.

Caregiver information

Caregiver full name *

Relationship to child *

Email address *

Phone number *

Preferred contact method *

Shipping information

Street address *

Apartment, suite, or unit

City *

State *

ZIP code *

About the child

Child’s first name *

Age range *

Pronouns (optional)

Preferred language *

Interests, favorite colors, or activities

Accessibility, sensory, reading, or communication needs

Loss and resource needs

Child’s relationship to the person who died *

When did the loss occur? *

What would you like our team to know?

How did you hear about Green Heart?

Permission and staying connected

I confirm that I am the child’s parent or authorized caregiver and give Green Heart Inc. permission to contact me about this request. *I would like to receive Green Heart’s future monthly family newsletter, resources, and event updates. I understand I can unsubscribe at any time.I understand this request is for educational resources and connection to support, not emergency, medical, or mental health treatment. *

We collect this information only to review your request, communicate with your family, prepare and ship resources, and send updates if you choose them. Please do not include medical records, Social Security numbers, or other highly sensitive information.

Tell us how we can support your child.

Caregiver registration