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

Registration, Consent, Release and Waiver for Participation in Companions on a Journey's Adult & Family Grief Support Programs

Thank you for taking the time to carefully read and answer every question! We offer grief support services including programs, groups, and events at no charge to the community. This would not be possible without generous donations and grant funding. As such, some of the information in the following questions being asked will be used for grant purposes. Specifically, many grants require statistics on demographics to track if a population is underrepresented or underserved, which is why we include questions related to it on this form.
Participant's Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState (2 Letter Abbreviation)

Zip CodeCountry
Gender of Participant
Race of Participant
Emergency Contact*

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

MonthDayYear
Date
Date of Death

MonthDayYear
Date
The person(s) the participant is missing:*

ChildSpouseMotherFatherGrandparentBrotherSisterAuntUncleCousinFriendPartnerGrandchildOther
Type of death/loss:*

IllnessAccidentSuicideMurderIncarcerationDeportationOverdoseOther
Additional losses you would like to share with us:
Are there topics or questions that you would like us to cover?
Have you attended other grief programs, groups, or event?

YesNo
If yes, please provide the name of the program, group, or event.
Have you attended a group with Companions on a Journey?

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

ReferralSocial MediaWebsite
If by referral, please provide the name of the person or organization who referred you:
Which group(s) are you registering for?*

Bereaved Parent - Grief support for parents who have suffered the death of a childHope and Healing After a Suicide Loss - Compassionate community for any adult who has had a loved one die by suicide.Young Widowed (20-65) - Support for those who have lost a spouse.New Beginnings/Living Again (65+) - Support for those who have lost a spouse.Caring for Your Grieving Soul (Gate of Heaven) - Support for adults who have suffered the death of a loved one.Men in Grief - Grief support for men who have suffered the death of a loved one or friend.Grief to Peace - Open grief group hosted by The Spring Grove Funeral Homes.New Adventures Widowed Support Group (Social Activities)Mending Hearts for Grieving Children, Teens, and Families
Single tag
Tags to map
Please provide the first and last name and the age of all child(ren) that will participate in the Mending Hearts Support Program with you.
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 & Release*

I grant permission to Companions on a Journey to use my name, image, voice and/or testimonial in any of their publications, presentations, websites, social media platforms or other media channels. I understand that this consent is voluntary and I can withdraw it at any time by contacting Companions on a Journey by phone or email. I also understand that I will not receive any compensation or royalties for the use of my name, image, voice and/or testimonial.I do not grant media permission to Companions on a Journey.
Media Consent and Release for Children Participating in the Mending Hearts Program*

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.
Consent to Participate in Grief Support Group(s), Attend Events, Release and Waiver
I give my consent for the participant (and if registering for Mending Hearts for all minors listed above) to participate in COJ's in-person and virtual programs, groups, and events. Without payment or additional consideration, my consent to participate also grants COJ, and its agents, employees, successors and assigns the absolute right and permission to use photographic portraits, pictures, digital images, video and voice recordings of myself and if applicable my child, including reproductions regardless of format, in which I or my child may be included in whole or part, for any lawful purpose whatsoever, including use in any COJ publication or website. COJ uses media to showcase our work to the community, grants, and generous funders. These materials are for informational and promotional purposes only and do not include names or identifying details to protect individuals' privacy.

Companions on a Journey Grief Support (COJ) is a faith-based social service organization that provides bereavement support and educational services for children, teens, and adults. COJ is a section 501(c)(3) non-profit bereavement support organization. COJ does not provide any counseling related services which require a license under Chapter 4757 of the Ohio Revised Code. COJ support groups, educational services, crisis response, grief support sessions, and events should not be considered a substitute for mental health therapy. Our facilitated groups involve discussion, sharing, and recognition of different perspectives, and facilitators strive to create an inclusive environment for the purpose of working through grief.

I acknowledge that while COJ and its agents, employees and volunteers will undertake reasonable care for participants, no activity is risk free. I acknowledge and agree on my behalf and if I have granted permission for a minor participant to participate on behalf of the minor participant that:

1. COJ does not maintain health insurance for injuries to Participant that may arise out of involvement in the program.
2. COJ does not provide supervision for Participant before or after scheduled programs.
3. By virtue of participation, Participant risks illness, injury, including those injuries that result from the circumstances or actions of persons who are not employees or agents of COJ.
4. I knowingly and freely assume all such risk.
5. On behalf of myself, and if applicable, the minor participant for whom I am the parent/legal guardian as well as for all heirs, assigns and next of kin of mine and the minor participant for whom I am acting on behalf, I release, indemnify, and hold harmless and promise not to sue COJ, its board of directors, advisory board members, employees, agents and volunteers (collectively, “Released Parties”) for any and all loss or damage, and any and all claims that may now exist or arise in the future which relate to their participation in COJ programs, groups and events, including, but not limited to, those resulting from the negligence of one or more of the Released Parties.
6. If the Participant requires any emergency medical procedures or treatments while participating in a COJ Program, I consent to the Released Parties taking, arranging for, or consenting to the procedures or treatments at their discretion. I hereby release the Released Parties from and against any and all claims and liability arising from or related to the provision, authorization and administration of medical treatment, services and medication to myself and/or to my child in accordance with this provision.

I represent that I am at least eighteen (18) years of age and am fully competent to sign this document, and Waiver and that all information I have provided is complete, true and accurate.
Signature*

Clear
By registering with Companions on a Journey to participate in support groups, you will be added to our email communications. You may unsubscribe from these communications at any time.
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Registration, Consent, Release and Waiver for Participation in Companions on a Journey's Adult & Family Grief Support Programs

Consent to Participate in Grief Support Group(s), Attend Events, Release and Waiver