Reflection Park Intake Form

Reflection Park Intake Form

Please share the details below so we can best support your needs.
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.
Please provide the 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
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*
Which area 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 OnlyDonation to Burial Assistance Fund (helps cover partial or total costs of a natural burial for families with financial need)Other
Your donation is truly appreciated. Please indicate the dollar amount you wish to donate: *
Please specify*
How many Adult Full Body Burial Packages do you intend to purchase?*
How many Interment Rights do you intend to purchase?*
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*
Please provide any additional considerations we should be aware of; for example, military or first responder honors, religious or cultural traditions, or anything else about your situation that would be helpful for us to understand.
Should be Empty: