Family Registration Form

Family Registration Form

Center for Hope and Healing
Thank you for Registering for services at the Center for Hope and Healing. You only need to fill this out one time.

After you have registered please RSVP to the groups you are interested in attending. You can RSVP to multiple months at a time.
Family Questions
Date*

MonthDayYear
Date
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
How did you hear about us?*
Please Specify
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Participating Family Members (please list all including self)*
How was the deceased related to each family member?*
The Gathering Table (2nd Wednesday)The Art of Connection (3rd Saturday)Support Group - Gardnerville (4th Thursday)Support Group - Carson City (Every Wednesday)
Questions About the Deceased
Name of *

First NameLast Name
Configurable list*
HomeHospitalHospiceWorkOther
Causes, Circumstance and Location of Death:*
Deceased's employer prior to death?*
Questions about your family
What other deaths have you, your child or teen experienced and approximate dates? (friends, relatives, pets, etc.)*
What other changes have you, your child or teen experienced (moved, changed schools, jobs, etc.) since the death?*
Extended FamilySupport GroupFriendsCoworkersChurchOther
Optional

These questions help us apply for grants to fund our programs and keep our services free.
Asian AmericanAfrican AmericanCaucasian/European AmericanLatin American/HispanicNative AmericanMiddle Eastern AmericanOther
Less than $25,000$25,000-$49,999$50,000-$74,999$75,000-$99,999$100,000-$149,999$150,000-$199,999$200,000 and abovePrefer not to answer
Less than $25,000$25,000-$49,999$50,000-$74,999$75,000-$99,999$100,000-$149,999$150,000-$199,999$200,000 and abovePrefer not to answer
Should be Empty:

Family Registration Form

Questions About the Deceased

Questions about your family

Optional