Grief Form

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Have you filled out a participant form in the past?
YESNO
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Name* This field is required.
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Address* This field is required.
4
Phone* This field is required.
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Email* This field is required.
example@example.com
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How do you prefer to be contacted* This field is required.
Text
Phone call
Email
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DOB* This field is required.
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Ethnicity* This field is required.
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Marital Status* This field is required.
10
Do you receive the following benefits?* This field is required.
SNAP , Food Stamps
Medicaid
TANF, Cash Assistance
Social Security Insurance
PACE or PACE NET
N/A
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How did you hear about the ECWC* This field is required.
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Emergency Contact/Phone Number* This field is required.
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Please tell us the name of the person you've lost.* This field is required.
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How was this person related to you?* This field is required.
15
Date of loss?* This field is required.
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What was their cancer diagnosis?* This field is required.
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Have you or are you seeing a professional for individual counseling?* This field is required.
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If yes, who?* This field is required.
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What are your wellness goals?
Physical Activity
Nutritional Guidance
Social Connection
Stress Management
Emotional Support
unsure
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Preferred Program Times
Weekday AM
Weekday Afternoons
Weekday PM
Saturday
Sunday
Unsure
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The ECWC has a Grief Support Group which meets twice a month and a Grief Journaling Group that meets once a month. In addition, you are welcome to attend any activities which are listed on our program calendar, with the exception of reiki and oncology massage. All our services are free of charge.

Photo Waiver: We want the community to see the great things we're doing at the ECWC. This will sometimes require pictures to be taken while classes are in session. Please sign below if we have your approval to take pictures where your face may or may not be visible.
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Signature
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Consent and Release: By submitting this form to the ECWC, I understand the following: I/we represent that the activities that I/we register for will be those that are appropriate for our physical condition and if they become beyond our abilities, I/we will ask for a modification or stop the activity. Our participation in all classes or services is voluntary and I/we consent to participate. I/we agree to hold Erie Cancer Wellness Center class(es) and/or its services, its directors, officers, employees and agents harmless from all liability and claims arising out of or in connection with my/our participation in classes/services. I/we hereby release and discharge ECWC from all liability arising out of or in connection with the class(es) and/or services. I/we understand that I/we are solely responsible for any loss or injury suffered by me, my child or my property resulting from our participation in classes/services. I/we understand that the employees and providers of the ECWC are mandated reporters and are required to report any suspected abuse/neglect to the authorities.
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Which programs interest you the most?
Support groups
Art Therapy
Meditation/Mindfulness
Movement Classes
Nutritional Guidance
Educational Workshops
Journaling
Art Therapy
Other
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