Peer Support Group Registration Form Peer Group Registration Form Adult #1 First Name * Last Name * Phone * Email * Reason for your interest in attending a Healing Hearts Peer Grief Support Group * Adult #2 First Name Last Name Phone Email Reason for your interest in attending a Healing Hearts Peer Grief Support Group Participating Child #1 First Name Last Name Age Grade School Gender M F Participating Child #2 First Name Last Name Age Grade School Gender M F Participating Child #3 First Name Last Name Age Grade School Gender M F What type of loss brings you to Healing Hearts? Death Divorce Separation Abandonment Incarceration Immigration Military Deployment OtherOther Which Program(s) do you or your family have interest in attending? Children's Group (Ages 6-12) Teen Group (Ages 13-18) Young Adult Group (Ages 19-30) Adult Group (Age 30 and over) For grant-writing purposes, please indicate the following Your family’s household income level Under $25,000 $25,000 - $50,000 Over $50,000 Do you qualify for free/reduced school lunch? Yes No Race or Ethnicity White Hispanic African American American Indian Asian/Pacific Islander If you are human, leave this field blank. Submit Registration
