Healing Helps Intake Form 2026

Which topic interest you the most? Number them in order.*

Rows	Priority
“Mapping My Feelings” – Identifying emotions grief may cause.
“My Healing Toolbox” – Creating coping tools for grief
“Letter to My Future Self” Encouraging growth and reflection through grief.

Do you have any dietary restrictions? *
Select Your Sandwich*
Choice of Bread*
Liability Waiver and Release
I hereby give permission to The Wallace Foundation to use photographs, videos, and other media taken of me during this event for promotional, educational, and other purposes. I understand that these images may be used in print, online, and other media formats.

I acknowledge that I will not receive any compensation for the use of these images. I also understand that I can withdraw my consent at any time.
Date*

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Signature*
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