This document is an information form for teens attending a monthly Teen Night activity. It requests the teen's name, contact information, age, birthdate, details about previous support group attendance, information about a deceased family member or friend including their name, relationship to the teen, date and cause of death, how the teen's life has been impacted, and what the teen is looking forward to at the event. The form must be returned before attending Teen Night.

1. Teen Night – Information Form
Thank you for filling out this short background form to help us plan our monthly Teen Night activities. As always, all information that you
share will be kept confidential. This form must be returned via fax (502-4564) or email (kgalvin@tedebearhollow.org) before you attend!
Teen’s Name: _________________________________________________ Today’s Date: ______________
Teen’s Email Address: _________________________________________________________________________
Parent’s Email Address: _______________________________________________________________________
Home #: __________________ Parent Cell #: __________________ Teen’s Cell #: __________________
Teen’s Age: _______ Teen’s Birthdate: __________________
What TEBH support groups have you attended? When? ____________________________________________
___________________________________________________________________________________________
Name of the Deceased: ________________________________________________________________________
Relationship to You: __________________________ When did they die? ___________________________
(Parent, Sibling, Spouse/Partner, Child, Grandparent, Friend, etc.) Month Year
How did the death occur? ______________________________________________________________________
___________________________________________________________________________________________
How would you describe your relationship with this person? _________________________________________
___________________________________________________________________________________________
In what ways has this death impacted your life? ___________________________________________________
___________________________________________________________________________________________
What brings you support or comfort now? ________________________________________________________
___________________________________________________________________________________________
What are you most looking forward to at Teen Night? ______________________________________________
___________________________________________________________________________________________