Days of Hope Registration Form

Days of Hope Registration Form

December 6, 2024
Days of Hope Agenda
- 9:45-10:00 AM: Registration and breakfast at Forrest General Tree Rooms
- 10:00-10:15 AM: Welcome and introductions at Forrest General Tree Rooms
- 10:15-11:30 AM: Opening Session with presentation by Cassie Cochran
- 12:00-3:00 PM: Return to programs for lunch and group sessions
- 3:30-4:00 PM: Spiritual send off at Pine Grove's Outpatient Services building
Name*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which Pine Grove program(s) have you attended?*

Gratitude/Gentle PathPEPNext StepWomen's CenterLegacy ProgramIntensive OutpatientFamily ProgramOther
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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Days of Hope Registration Form

ALUMNI STATEMENT OF CONFIDENTIALITY