GRIEFSHARE
Participant Information Registration Form
Support Group for those who have experienced the loss of a family
member or friend
Name
Date
Address
City
Zip Code
Home Phone
Cell Phone
Email
Date of Birth
Emergency Contact (name and local phone#)
What church you attend
Pastor's Name
Are you under a doctor care?
Yes
No
Name
Phone number
How did you find out about GriefShare
Whom have you lost in death
When
Briefly describe the nature of your loss
List name and ages of children that have been affected by the loss of your loved one
Is there a need or any special way that we can minister to you and your family?
Yes
No
How
Please read and commit to the following statement by printing your name:
I understand that confidentially is mandatory in my support group and that anything
said in the group stays in the group. I understand GriefShare is NOT counseling, but a
peer support group led by volunteers. I also understand the volunteers and leaders of
this program have a obligation to report any disclosure of intent to harm oneself or
others to the pastors at this host church, or to any appropriate agency.
Print Name
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