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GriefShare Registration Form

GriefShare Registration & Participant Information Form

First Presbyterian Church
4821 Bloom Ave., White Bear Lake, MN 55110
651-429-3381 • email: fpc-wbl@fpc-wbl.org • website: fpc-wbl.org

General Information:

Name
Address   City   State   Zip
Home Phone   Work Phone   Cell Phone  
Email 
Emergency contact person (name)   Phone 
What church do you attend?   Are you a member?  
Pastor’s Name   Church’s Phone 
Physician’s Name   Physician’s Phone

How did you hear about GriefShare?


Please share a little information about the person you lost and when the loss occurred.


Is there anything more about your situation you would like to share?



Registration fee: $15 (covers all 13 sessions)
Please send registration fee to First Presbyterian Church, 4821 Bloom Ave., White Bear Lake, MN 55110
Checks payable to First Presbyterian Church with "GriefShare Group" in the memo line.


I understand confidentiality is mandatory in my support group and that anything said in the group is to stay in the group. I understand GriefShare is not counseling, but a peer support group led by volunteers. I also understand that volunteers and/or leaders of this program have an obligation to report any disclosure of intent to harm oneself or others to the pastor at First Presbyterian Church, my church or to any other appropriate agency.


Electronic Signature
Date


You must enter the Authentication Text on the next page and click Submit to finish the registration process.