Grief Group Interest Form
Scenic Bluffs is planning a 12-week Grief Support Group this spring and would value your input. We are gathering feedback from interested participants to help determine the best start date, day of the week, and time for the group. If you are interested in participating, please complete the form below and share your availability. We will contact you once the schedule has been finalized.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What months would you be available to participate in this group? Please select all that apply.
April
May
June
What day of the week works best for you to meet in person at Scenic Bluffs in Cashton? Please select all that apply.
Tuesday
Wednesday
With your above selections in mind, what time of day works best for you to meet in-person at Scenic Bluffs in Cashton? Please select all that apply.
Early morning (7 AM- 8 AM)
Morning (Between 8 AM-10 AM)
Mid-Morning (Between 10 AM- 12 PM)
Afternoon (Between 12 PM-2 PM)
Mid-Afternoon (Between 2 PM- 4 PM)
Evening (Between 4 PM-7 PM)
Other
Comment
Submit
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