Alumni Days of Hope - September 9, 2022

Alumni Days of Hope Registration Form

September 9, 2022 | 9:30 AM to 4:00 PM
This upcoming Days of Hope will be an "in-person" event. Presentations and program sessions will also be streamed via Zoom. Registration is required to attend the in-person or virtual Zoom sessions.

Day of Hope Agenda
- 9:30-10:00 AM: Registration and breakfast at Pine Grove's Wicker Building (218 S. 28th Ave)
- 10:00-10:15 AM: Welcome and introductions at Pine Grove's Wicker Building (Zoom available)
- 10:15-11:30 AM: Opening Session with presentation by keynote speaker (Zoom available)
- 11:30-3:15 PM: Alumni and family return to programs for lunch and group sessions (Zoom available)
- 3:30-4:00 PM: Spiritual send off at Pine Grove's Pavilion (2255 Broadway Drive)
Name *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province
Which Pine Grove program(s) have you attended? *

Gratitude/Gentle Path PEP Next Step Women's Center Legacy Program Family Program Other
Do you plan to attend this event in-person? *

Yes, I plan to attend the event in-person. No, I plan to attend the Zoom sessions.
# of additional Guest (if attending in-person)
ALUMNI STATEMENT OF CONFIDENTIALITY
By Participating in the program of Pine Grove Behavioral Health or in any aspect of the program, you will be privy to certain confidential information in regard to other program participants.

Any information regarding a person’s presence in this program or items discussed by these persons is strictly confidential and redisclosure of either is prohibited by Federal Regulation (42 CFR Part 2).

I, {name}, have read the above statement and understand that I am responsible for maintaining the confidentiality of all persons participating in this program and for making no further disclosure of information obtained here. I am also aware that certain confidential information of mine may be disclosed or inferred by my participation and I consent to such disclosure evidenced by my participation. If I choose to participate via a video teleconference offered by Pine Grove Behavioral Health & Addiction Services, I have been informed and understand that doing so may pose a potential privacy risk and agree to such risk.
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Alumni Days of Hope Registration Form

ALUMNI STATEMENT OF CONFIDENTIALITY