Join Kate's Club

Thank you for your interest in Kate's Club...

Please take a moment to fill-out the application as best as you can. The application is only a few pages long and will require approximately, 20 to 30 minutes.

Other ways to apply

We offer various ways to apply, if you prefer to print the application and send via email, fax or traditional USPS mail, please visit our application page for full details.

We try our very best to this process as easy and simple as possible, we are here for you and are available to help with any support needed.

Get in touch.

Do you know a Family who could benefit from Kate's Club?

If you know of a family that could benefit from Kate’s Club, please let them know about us! Our doors are always open to new members, and all programs are offered at no cost to families.

Grieving families generally appreciate it when extended family and friend reach out to them to acknowledge their loss, offer support and connect them with resources. Please spread the word about Kate’s Club and encourage parents/guardians to call Kate’s Club for more information.

Learn More

Kate’s Club staff is more than happy to speak with anyone interested by phone or personal appointment.

Give us a call at 404-347-7619.

Kate's Club Membership

Please complete and submit a separate form for each child wishing to join.

Location
Which city will you attend?*
Kate’s Club now offers a half-day program in Gainesville, GA once a month, along with our programs at our main location in Atlanta.
- Atlanta
- Gainesville (see note below)
Parent / Guardian Information
Relationship to child:
Full Name*
First Middle Last
Gender*
- Male
- Female
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Email is our preferred method of communication with you; please provide a current email address and keep us updated if it changes. If not email accessible, please indicate to call only.
Phone*
Alternate Phone
What keeps you busy?
Occupation
- I'm self-employed
- I work for a company
- Other
That's great, in a few words, tell us a little bit about it:
Place of Employment
How would you describe your occupation?
Current Living Situation
You can add as many individuals by clicking / tapping on the plus sign (+) at the end of the each rows.
Individuals living in child’s home:
Age Name Relationship to child
Child Information
Full Name*
First Last
Nickname
Birth date:*
MM slash DD slash YYYY
Age*
Please enter a number greater than or equal to 0.
Gender*
- Male
- Female
School (if applicable)
Grade Level (if applicable)
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Information about the Person Who Died
Please include as much information as you are comfortable providing. This helps us identify the needs and services that best fit your child’s unique loss. Please attach an additional page if needed.
Full name of person who died:
First Last
Relationship to child:
Guardian’s relationship to deceased:
Date of death:
Age at death (of person who died):
Cause of death:
- Accident
- Accidental Overdose
- Automobile Accident
- Cancer
- Chronic Illness
- Homicide
- Long-term Substance Abuse
- Medical Crisis
- Sudden
- Suicide
- Cause Unknown
- Other
Cause of death (other):
Did the child witness the death?
- Yes
- No
Was this person a primary caregiver to the child?
- Yes
- No
Did the child live with the person who died?
- Yes
- No
Please describe the child’s relationship with the person who died.
- Extremely Close
- Close
- Strained
- Distant
- No contact at all
Additional information about the death:
Additional Information
Please help us learn more about your child. Feel free to include as much information as you would like. Please attach an additional page if needed.
My child has SHOWN the following behaviors SINCE the death:
- Acting Out
- Aggression
- Anxiety
- Bullying behaviors
- Changes in eating
- Changes in sleeping
- Clinging behaviors
- Crying
- Depression
- Drop in grades
- Fantasizing about own death
- Isolation/withdrawal
- Nightmares
- PTSD
- Regression
- School avoidance
- Somaticizing
- Substance abuse
- Talk of suicide
- Trouble concentrating
- Victim of bullying
- Other behaviors
Other behaviors my child has SHOWN SINCE the death:
The behaviors that I am most concerned about with my child since the death include:
My child has EXPERIENCED the following events SINCE the death:
- Abuse
- Divorce
- Foster Care
- Involvement in Justice System
- Loss of friend(s)
- Moving
- New siblings
- Physical disability
- Remarriage
- School change
- Separation
- Other experiences
Other events my child EXPERIENCED SINCE the death:
Please list any losses your child experienced PRIOR to the death:
Please list any additional losses your child experienced SINCE the death:
Has your child and/or family received counseling?
- Yes
- No
Please tell us if your child has:
Health problems, behavior problems, ADHD, Autism, developmental delays, special needs, allergies, medications (if any):
Emergency Contact Information
Someone other than parent/guardian.
Name
First Last
Relationship to child:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Main Phone:
Alternate Phone:
Expectations
What are your expectations of Kate’s Club for the CHILD / TEEN joining?
- Meeting other kids who are grieving
- Opening up to discussing loss and grief
- Learning ways to cope with grief
- Expressing feelings
- Other expectations
Other expectations for the CHILD / TEEN
What are your expectations of Kate’s Club for YOURSELF and your FAMILY?
- Meeting other families of grieving children
- Learning ways to share feelings as a family
- Learning how to support the grieving child in your care
- Other expectations
Other expectations for for YOURSELF and /or your FAMILY
Record Keeping and Grant Reporting
This information will be kept confidential and will only be reported anonymously.
How did you hear about Kate’s Club?
Please be specific. Include the name of the person and/or the school, agency, organization or publication that referred you:
Child’s Ethnicity
- Asian/Pacific Island
- Black/African American
- Latino/Hispanic
- Native American
- White/Caucasian
- Other ethnicity
Other ethnicity (optional)
Is your child eligible for free or reduced lunch at school?
- Yes
- No
Application Verification Signature
I hereby certify that all of the answers given by me on this application are true to the best of my knowledge. I understand that my family will be contacted upon review of this completed application to complete the membership process.
Signature
Full Name Date
Signature*

Use the space above to sign your name.
Artwork, Photographs, and Video Images
I authorize Kate’s Club and/or assignees or licensees to use art, photographs and/or video images of my child for reproduction for promotional, illustrative, or educational purposes. I understand that the above activities will not result in any profit, and that I will not receive any monetary compensation. Permission is granted to make changes or alterations and to use my child’s name or a fictitious name in editorial works or advertising. I understand that Kate’s Club takes photographs of the members and families during programs and may share the images in program communications. I give permission and understand that my child and family may be photographed and/or videotaped at Kate’s Club programs and events.
Signature
Full Name Date
Signature*

Use the space above to sign your name.
Emergency Medical Treatment Release (please check one and sign below)
Please select one of the options and sign below
To have my child receive any emergency medical services deemed necessary by the authorities in charge. I understand that the resulting expenses will be my responsibility as the child’s parent/guardian. I further agree to release, discharge and indemnify Kate’s Club, its Officers, Board of Directors, Employees and Agents from any and all liability, damages, claims or causes of action, arising out of or in any way connected to the administration of emergency medical services.
- I agree
- I do not agree
Kate’s Club Outings/Activities Release
I agree to release and forever discharge Kate’s Club, its Officers, Board of Directors, Employees and Agents, and all vessels and facilities owned and/or operated by Kate’s Club (hereinafter “Released Parties”) from any and all liability, damages, claims or causes of action, arising out of or in any way connected with the minor’s participation in Kate’s Club outings and activities. I further agree to indemnify the Released Parties and hold them harmless from any liability, damages, claims, or causes of action made or brought by the said minor or by anyone on behalf of the minor as a result of or in any way connected with the minor’s participation in Kate’s Club outings and activities. The undersigned acknowledges that the outings and activities addressed by this release are completely VOLUNTARY.
Signature
Full Name Date
Signature*

Use the space above to sign your name.

You're doing great!

In the next section we will ask you about the child you wish to join Kate's Club

Let's continue.

Join Kate's Club

Thank you for your interest in Kate's Club...

Other ways to apply

Do you know a Family who could benefit from Kate's Club?

Learn More

Give us a call at 404-347-7619.

Kate's Club Membership

Location

Parent / Guardian Information

What keeps you busy?

Current Living Situation

Child Information

Information about the Person Who Died

Additional Information

Emergency Contact Information

Expectations

Record Keeping and Grant Reporting

Application Verification Signature

Artwork, Photographs, and Video Images

Emergency Medical Treatment Release (please check one and sign below)

Kate’s Club Outings/Activities Release

You're doing great!

In the next section we will ask you about the child you wish to join Kate's Club

Kate's Club

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Age	Name	Relationship to child