New Group Member Registration

New Group Member Registration

Welcome! We’re honored to walk with you through this season. Please complete this form so our team can help place you in the group that will best support you on your healing journey.
Contact Information

Self, Parent, or Guardian Information
Name:

First NameLast Name
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
Email is used for group and ministry updates.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Emergency Contact:
About Your Loved One
Their name:

First NameLast Name
Their Age:
Relationship to you:
Specific relationship to your loved one:
Date of loss:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Situation of loss:
Situation details:
Would you like to share anything else about this loss?
Have you experienced the loss of anyone else you would like us to know about?
If yes, please tell us about any additional losses you would like us to know about.
About your loved one
Session Registration

Select the group you'd like to join—whether it's upcoming or already meeting. You are welcome to join at any time.
Session 1: Completed

Session 2: Completed

Session 3: August 11 - October 22 2026

Session 4: November 10 - December 29 2026
Session:
Which group are you registering for?:
Which time are you registering for?
Children and Youth

If no children or youth are attending, please skip this section
Are you bringing any children & youth who will be attending a group or childcare?
Child or youth Information
About
What to Expect

Groups meet once a week for about an hour, depending on the group and session. Our groups are free of charge and designed for your benefit—the more you attend, the more you’ll gain. Average group sizes are under 10 participants, creating a small, intimate space where you can feel safe to share and connect. Childcare is available for select sessions—please see the program schedule for details.
Privacy and Confidentiality Policy

Heart of the Cumberland, through its dedicated volunteers, staff, and board, makes every effort to keep what is shared by group members confidential and encourages group members to do the same. Information provided to Heart of the Cumberland will only be used for the express purpose for which it is gathered. All files are and will remain the exclusive property of Heart of the Cumberland. Group member contact information is securely maintained and is shared only with group facilitators for program-related purposes.

Our confidentiality policy will be strictly maintained except in the following circumstances (including, but not limited to):
- Suicidal expressions
- Suspected physical, mental, or sexual abuse, which by law must be reported (Tennessee Code Annotated 37-1-403(i)(1))
- Suspected drug or alcohol use/abuse by a child
- Mandates of the court
How did you hear about Heart of the Cumberland?
Please tell us more (optional):
By typing my name below, I acknowledge that I have read, understand, and agree to abide by the confidentiality policy and peer group definition outlined on this form.

First NameLast Name
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Session Import ID
Salesforce Group
Session Time Slot
Should be Empty:

New Group Member Registration

Contact Information

About Your Loved One

Session Registration

Children and Youth

About