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Participant Information Form

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First Name * Last Name * Address * City * State * Zip * Email Address * Confirm Email Address * Date of Birth (month/day) * Church you attend * Emergency Contact (name and phone number)* How did you hear about GriefShare? * Whom have you lost in death?* Date of Death * Briefly describe the nature of your loss * If you have children, what are their ages and gender? * Is there anything more about your situation you would like to share? *

I understand confIdentIalIty Is mandatory In my group and that anythIng saId In the group Is to stay In the group. I understand grIefshare Is not counselIng, but a group led by volunteers. I also understand the volunteers and/or leaders of thIs program have an oblIgatIon to report any dIsclosure of Intent to harm oneself or others to the pastors at [host church], my church, or to any other approprIate agency.

Sign Name* Signature Date*

Gill Creek Baptist Church

Group Member Agreement

Participant Information Form