Grief Care
Registration Form Everyone’s loss and grief are unique. This information will enable the facilitators to better help you in your unique journey. Please print clearly: Your name: ___________________________________________________________________ Street address: _________________________________________________________________ City: _______________________________ Province: ________ Postal Code: ____________ Home phone: (
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Cell phone: (
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Email address: _________________________________________________________________ Emergency contact (name, relationship, cell phone/text number): _________________________ ______________________________________________________________________________ Your date of birth (month/day): ____________________________/_______________________ How did you hear about Grief Care? _______________________________________________ ______________________________________________________________________________ Have you participated in a grief support group before? If so, when _______________________ where _______________________ and program name _________________________________ Have you/are you presently receiving profession grief counselling ? Y _________ N _________ Grief Care is based on a biblical/Christian worldview, but you do not need to be a Christian to attend. We want you to feel welcome no matter what your beliefs are, and we will respect that by not engaging in theological or doctrinal debates. If you are comfortable in doing so, please check below the statement that best describes you: ______ I attend church regularly. Church name __________________________________ ______ I do not attend church regularly, but consider myself to be a Christian. ______ I follow another faith tradition, which is _________________________________ ______ I do not follow any faith tradition.
Please complete side two.