Registration and Consent to Participate in COJ's Virtual Bereavement Support Groups

Registration and Consent to Participate COJ's In-Person and Virtual Bereavement Support Programs
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State (2 Letter Abbreviation)

Zip Code Country
Gender of Participant
Race of Participant
Phone Number *
Email *
example@example.com
Emergency Contact *

First Name Last Name
Emergency Contact Phone *
Tell us about your loved one.
Name
Date of Birth

Month Day Year
Date
Date of Death

Month Day Year
Date
The person who died is my:

Child Spouse Mother Father Grandparent Brother Sister Aunt Uncle Cousin Friend Partner
Type of death/loss:

Illness Accident Suicide Murder Incarceration Deportation
Additional losses you would like to share with us:
Are there topics or questions that you would like us to cover?
Have you attended a grief group before?

Yes No
If yes, please provide the name of the group.
Have you attended a group with Companions on a Journey?

Yes No
If yes, please provide how long.
Which group(s) are you registering for? *
Please provide the first and last name and the age of all child(ren) that will participate in the Mending Hearts or Family Facilitation Support Programs with you.
Please, select one or both of the consent options below to indicate your consent to participate in online and/or in-person groups.
Consent to Participate in Online Support Group(s) *

By clicking this box, I give my consent to participate in Online Companions on a Journey's Bereavement Programs. All of the information I have provided is true and accurate. I do not consent to Online Companions on a Journey's Bereavement Programs.
Consent to Participate with In-Person Support Group(s) *

By clicking this box, I give my consent to participate with In-Person Companions on a Journey's Bereavement Programs. All of the information I have provided is true and accurate. I do not consent to In-Person Companions on a Journey's Bereavement Programs.
Media Consent and Release

I hereby grant Companions on a Journey, and their agents the absolute right and permission to use photographic portraits, pictures, digital images or videotapes of my child, or in which my child may be included in whole or part, or reproductions thereof in color or otherwise for any lawful purpose whatsoever, including but not limited to use in any Companions on a Journey publication or on their website, without payment or any other consideration.

I hereby waive any right that I may have to inspect and/or approve the finished product or the copy that may be used in connection therewith, wherein my child’s likeness appears, or the use to which it may be applied.

I hereby release, discharge, and agree to indemnify and hold harmless Companions on a Journey and their agents from all claims, demands, and causes of action that I or my child have or may have by reason of this authorization or use of my child’s photographic portraits, pictures, digital images or videotapes, including any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said images or videotapes, or in processing tending towards the completion of the finished product, including publication on the internet, in brochures, or any other advertisements or promotional materials.

I represent that I am at least eighteen (18) years of age and am fully competent to sign this Release.
Consent for Media Release *

CONSENT: I hereby certify that I am the parent or guardian of the above-named child(ren) and do hereby give my consent without reservation to the foregoing on behalf of my child. NON-CONSENT: I hereby certify that I am the parent or guardian of the above-named child(ren) and do not hereby give my consent without reservation to the foregoing on behalf of my child.
Signature - use your mouse or pad to complete *

Clear
How did you hear about Companions on a Journey? *

Referral Social Media Website
By registering with Companions on a Journey to participate in support groups, you will be added to our email communications. You may unsubscribe to these communications at any time.
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Registration and Consent to Participate COJ's In-Person and Virtual Bereavement Support Programs