Reflection Park Intake Form

There are Three Roles when making advance arrangements for burial:

Purchaser
The person who will pay for the Purchase Agreement.

Owner
The person(s) authorizing Reflection Park to open the grave plot and support the burial of an individual in it (also called the Owner of the Interment Right).

Beneficiary
The person(s) who will be buried in the grave plot.
Purchaser's Information
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
What other role(s) does the Purchaser have?*

OwnerBeneficiaryBoth Owner & BeneficiaryNo other role
Additional Owners and Beneficiaries
Add additional Owners?*
Please add the name and contact information of additional Owner(s)*
Add additional Beneficiaries?*
Please add the name and contact information of additional Beneficiaries*
Preferences for Burial Arrangements
Which burial section of Reflection Park feels most fitting for your needs? *
Which of the following items below would you like included in your Purchase Agreement? Check all that apply:*

Adult Full Body Burial Package (Interment Right + Interment Fee)Interment Right OnlyOptional donation to Harmony Fund for Memorial Trees, Equity Fund for Burial Assistance, or Care Fund for General OperationsOther (for example, casket or burial shroud)
You can read more about our tax-deductible donation funds at https://reflectionpark.org/donate
Your donation is truly appreciated. Please indicate the fund to which you wish to donate and the dollar amount: *
Please specify*
How many Adult Full Body Burial Packages do you intend to purchase?*
How many Interment Rights do you intend to purchase?*
Please choose the payment option that feels most comfortable. Payment plan terms extend up to 24 months maximum. All payment plans are interest-free.*

One-time payment (pay in full)10% down, followed by 12 monthly payments20% down, followed by 24 monthly paymentsOther (for example, 50% down followed by 12 monthly payments)
Please note, if choosing a payment plan, Reflection Park will store credit card or ACH information in our secure payment system for the purpose of automated withdrawals.
Please specify*
Please provide any additional considerations we should be aware of. These might include military or first responder honors; religious or cultural traditions; preferences for a casket, carrier, or shroud; desired officiant or celebrant; preferred funeral home; or anything else about your situation that would be helpful for us to understand.
Next of Kin / Designated Representative

To help ensure your wishes are honored in the future, please provide information for one or more persons you would like us to keep in contact with, such as a next of kin or designated representative.
Next of Kin/Designated Representative Name

First NameLast Name
Next of Kin/Designated Representative Email
example@example.com
Next of Kin/Designated Representative Phone Number
Please enter a valid phone number.
Next of Kin/Designated Representative Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to you
Would you like to add another person?
Please provide contact information of additional Next of Kin/Designated Representative*
Stay Connected with Reflection Park

Reflection Park occasionally sends emails and newsletters with updates, events and community news.
Please let us know your preference:*

Include me on the Reflection Park mailing list if I am not already signed upDo not include me on the mailing list
Should be Empty:

Purchaser's Information

Additional Owners and Beneficiaries

Preferences for Burial Arrangements

Next of Kin / Designated Representative

Stay Connected with Reflection Park