Enrollment

We are excited to meet you and have you join our community! Please note that if you are over the age of 16, you may enroll yourself, but if you are 15 or younger, you need to have an adult complete the enrollment form on your behalf, in compliance with the Children's Online Privacy Protection Act.

Once you submit the form, our Bereaved Youth Village Onboarding Team will be in touch to provide more information and welcome you aboard! Please submit one form for each child.

Child's First & Last Name

Child's Date of Birth (MM/DD/YEAR)*

Child's Address

Parent or Child's Instagram Handle

Ethnicity*

How did you hear about us? *

Which type of loss did the child experience?*

If you would, please share when the parent(s) passed away and their name(s):

How the parent(s) passed away

Guardian Full Name

Guardian Relationship to Child

Guardian Address

Guardian Email

Guardian Phone Number

Guardian Shirt Size*

Youth Shirt Size*

Favorite Cookie Flavor*

WELCOME TO BEREAVED YOUTH VILLAGE!!!