School-based Grief Support Program - Interest Form
SCHOOL INFORMATION
School Name
*
School Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Phone Number
*
Format: (000) 000-0000.
School District
*
School Principal
*
Have you had a grief group at your school in the past?
*
Yes
No
CONTACT INFORMATION
Name
*
First Name
Last Name
Title/Position
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
How did you hear about Companions on Journey's School-based Grief Support Program?
*
Why are you seeking support from Companions on a Journey at this time?
*
GROUP INFORMATION
What is the grade range for the students in this group?
*
Can you identify at least five (5) students to participate in the group with completed paperwork?
*
Yes
No
Are there specific days of the week or times of day that work best to schedule your group(s)?
*
Companions on a Journey seeks to be your partner in supporting grieving students and staff throughout the school year (and from year to year). We ask that our school partners work with us to secure funding through their school, district, or local community foundations. Are you able to partner with us to secure funding of $1,750 per school year to help offset our cost of group facilitation and supplies?
*
Yes
No
Unsure
Any additional comments or questions for our staff?
Submit
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