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

Registration and Consent to Participate in Virtual and/or In-Person Bereavement Support Groups
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State (2 Letter Abbreviation)

Zip Code Country
Phone Number *
Email *
example@example.com
Emergency Contact *

First Name Last Name
Emergency Contact Phone *
Tell us about your loved one.
The person who died is my:

Spouse Mother Father Grandparent Brother Sister Aunt Uncle Cousin Friend
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, 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 Groups. All of the information I have provided is true and accurate. I do not consent to Online Companions on a Journey's Bereavement Groups.
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 Groups. All of the information I have provided is true and accurate. I do not consent to In-Person Companions on a Journey's Bereavement Groups.
Signature *

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Registration and Consent to Participate in Virtual and/or In-Person Bereavement Support Groups