Grief Retreat General Registration ⚠️ Registration Form Due March 27, 2023 at 11:59pm Welcome to Grief Retreat Registration for 2023! Parent/Guardian, please fill out the application and verify parental releases. Contact Harlie Blauw for questions regarding this registration. Note: You will have the opportunity to submit a digital picture of your deceased loved one(s) to be used in a presentation for honoring and remembering. This is optional. Student's Legal First Name * Student's Legal Last Name * Age * Birthdate * Race *BlackHispanicAmerican IndianAsianWhiteOther Other Race * Parent/Guardian Information Student Lives With (Please select all applicable) FatherMotherStepfatherStepmotherLegal Guardian Parent/Guardian Name * Relationship * Phone *0 / 10 Is this an emergency contact? *YesNo The Parent/Guardian contact(s) you listed were marked as no emergency contact. Please provide an emergency contact below: Emergency Contact Name Relationship Phone Activity Preferences We want you to have the most fulfilling experience that you can while attending this retreat, and part of that is having a voice in the activities you will participate in that day. Each of the activities described below have been thoughtfully developed and will offer you a unique experience in processing your grief. Please rank each of the activities listed 1-6, by your preference to participate in each with 1-Most interested & 6-Least interested. We will do our best to accommodate you. You will be able to participate in two activities. Clay *Participants will use their hands to push and manipulate the clay to create a bird or fish. The process will be a pinch pot method. The instructor will have examples and demonstrate the process while encouraging creativity and enjoyment. No previous experience required. Creative Writing *People live on through treasured memories and stories. In this workshop, healing happens through creative writing inspired by the losses we are grieving. No previous experience required. Paint *Attendees will help paint a temporary 8ft x 12ft mural by leaving behind their own touch. No previous experience required. Mixed Media *While listening to different styles of music, the students will create several abstract pieces. Students will then tear up their art and reassemble them in a collage format, taking pieces from all the individual works to create a whole new piece. No previous experience required. Watercolor on Canvas *Explore creative design using Walter Anderson’s 7 motifs and watercolor painting. If you haven’t heard of the 7 motifs, they are simple design elements that anyone can draw. When they are paired with watercolor paints, your creative possibilities are endless. Woodburning Artwork *Students will “draw” into the wood to create a contour line drawing of animals or plants. Templates will be available for use if needed or students may draw from their own creativity. Come explore burning away the past to create a new creation. Picture of Loved One(s) If applicable: We are asking that you submit a photograph of your deceased loved one(s) in advance. Please advise that these pictures will be shared at the retreat to honor and remember. Upload Picture(s) Drag and Drop (or) Choose Files Description(s) of the uploaded picture(s) Loss History Select One:DeathDivorceSeparationAbsenceOTHER: OTHER * Details of Loss Relationship: Date of Loss: Cause of Loss: Level of Support Received Support Received (if any)Informal (family & friends)Formal (support groups/individual counseling)None (has not/will not discuss) Add additional loss history Loss History Select One:DeathDivorceSeparationAbsenceOTHER: OTHER * Details of Loss Relationship: Date of Loss: Cause of Loss: Permissions Media Release: Participants will be expected to refrain from taking photography or videography of others without direct permission. Documentation photos of participants will not be taken during small group sessions. Non-Discrimination: The Mississippi School of the Arts, operated by the Mississippi Department of Education and the MSA Foundation, does not discriminate on the basis of race, color, national origin, sex, disability, religion or age in the admission to and provision of educational programs, activities and services or employment opportunities and benefits. Overall Permission to Participate: In the event that Mississippi School of the Arts staff cannot contact anyone listed as primary or Emergency Contact in a timely manner, I hereby authorize the MSA staff to use their best judgement in the caring for my child, by providing transportation or fulfilling other essential needs until I can be contacted. I hereby further agree and bind myself to defend, indemnify, and hold harmless the Mississippi School of the Arts and the Mississippi Department of Education from any liability or loss occasioned by any injury or damage sustained by my child during emergency or disaster situations or circumstances. Your Digital Signature (type your first and last name) * Today's Date * Send Message