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 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
