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2026 Angel Wings Retreat Registration

Our Angel Wings Retreat is a two-day bereavement group for children and teens who are grieving the loss of a loved one. We provide emotional and physical support in a safe, non-judgmental environment, where children ages 6 to 15 can explore their thoughts and feelings about loss alongside their peers. The retreat creates a space for remembering loved ones with other children who can relate to their situation.

"*" indicates required fields

Child's Name*

First Last

Child's Date of Birth*

MM slash DD slash YYYY

Child's Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Has your child ever attended the Southcoast Health Angel Wings Retreat?*

Yes

No

If yes, How many times?

How did you learn about the Southcoast Health Angel Wings Retreat?

Child’s T-Shirt Size:

Youth Small

Youth Medium

Youth Large

Youth XL

Adult Small

Adult Medium

Adult Large

Adult XL

Adult XXL

Adult XXXL

Parent / Guardian Name*

First Last

Parent / Guardian Preferred Phone*

Parent / Guardian Email*

Parent / Guardian Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Name*

First Last

Emergency Contact's Relationship to Camper:*

Emergency Contact's Preferred Phone Number for Days of Retreat*

Does your insurance mandate a Hospital?*

Yes

No

Hospital of choice?*

Does your child have any allergies? If yes, please provide specific allergies. If no put N/A. If your child has specific food allergies, please list them below.*

Does your child take medications? If yes, what are the medications treating? If no put N/A.*

Will your child be taking any medications at the retreat?*

Yes

No

Medical Disabilities (Please check any that apply.)

ADD

ADHD

Autism

Asthma

Diabetes

Headaches/Stomachaches

Hearing Impaired

Learning Disability

Mobility Impaired

Visually Impaired

Does your child have any of the following?

Other (Please Specify)

Is your child currently under the care of a physician?*

Yes

No

If yes, Physician’s Name and Phone Number*

What is the date of your child’s last tetanus shot?*

MM slash DD slash YYYY

BEREAVEMENT HISTORY

Please include as many details as possible when answering the following questions. We understand that answering some of these questions might be difficult; however, we want to be able to provide the best possible care for your child.

Child’s Name*

First Last

Name of Deceased*

First Last

Relationship to child:*

Date of Death*

MM slash DD slash YYYY

* Death must have occurred prior to 4/11/2026.

Age of child at time of death*

Was the deceased receiving Hospice services at the time of death?*

Yes

No

Was the death anticipated or sudden?*

What was the deceased’s cause of death?*

Please check if the following statement is true:

Child/Adolescent has not been told the facts about the deceased’s cause of death.

If checked, please explain what your child has been told about the cause of death

Is this your child’s first experience with death?*

Yes

No

If no, please comment on other deaths your child has experienced

Where did this person die?

Was the child present at the time of death?*

Yes

No

Did the child see the deceased after the death?*

Yes

No

Was there a funeral, wake or memorial service?*

Yes

No

If yes, did your child attend and what were your child’s comments/reactions to the service?

Did the child live with the deceased?*

Yes

No

How would you describe the child’s relationship with the deceased?

Does your child speak openly of the person who died?*

Yes

No

Please explain how your child shows that he/she is grieving.

Since this death, is your child displaying any behaviors/moods that have you concerned? If yes, please explain

Has your child exhibited any of the following since the death of the loved one? Check all that apply

Withdrawn/Isolation

Suicidal thoughts/talk

Causing harm to self

Behavior problems at school

Behavior problems at home

Loss of interest in usual activities

Inappropriate sexual behavior

Special fears

Worries about his/her safety or safety of others

Running away from home

Headaches, stomach aches

Nightmares

Belief that death was his/her fault

Belief that death is punishment

Changes in interactions with others

Drug/Alcohol use

Destruction of property

Changes in how he/she feels about self

Causing harm to others

Lying

Stealing

Anger

Other

Other

Has your child received any professional support?*

Yes

No

If yes, is support currently being provided?

Other than this death, have there been any changes/stresses in your child’s life (i.e. illness, divorce, relocation, remarriage, finances, other losses?)*

Yes

No

If yes, please explain:

Has your child ever experienced abuse of any kind?*

Yes

No

If yes, please explain

Describe your child’s personality/character traits.*

Are there any other special needs, family customs, or cultural aspects to your child’s grieving that we should be aware of?

We are proud to serve our community as a not-for-profit health system and our region’s largest employer. By providing clinical excellence and compassionate care all over southeastern Massachusetts and Rhode Island.

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