DivorceCare Registration
Fill out this form for DivoceCare at First Presbyterian Church.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
How did you hear about DivorceCare?
Please share a little information about your separation or divorce.
Do you have any questions?
Please let us know your hopes for the group.
Confidentiality and program understanding acknowledgment
*
I understand confidentiality is mandatory in my small 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 understand volunteers/leaders must report any disclosure of intent to harm myself or others to the pastors at First Presbyterian Church of Harrisonburg, my church, or another appropriate agency.
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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