Holiday Hope Registration : What We Do : Mourning Hope Grief Center

Holiday Hope Registration

To register for the Holiday Hope program complete the Registration Form below. Once submitted, a Mourning Hope staff person will contact you directly with details and information about the event.

Name (Parent/Caregiver):

First Name *

Last Name *

Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Cell Phone (Required)

Cell Phone:

Email Address (Required)

Email Address:

Name of the person who died (Required)

Name of the person who died:

Date of death (month/day/year) (Required)

Date of death (month/day/year):

Circumstances of the death: (Required)

Decedent's relationship to you: (Required)

Decedent's relationship to you:

If "Other", please detail here:

Youth Name (Required)

First Youth Attending

Age (Required)

School Name (Required)

Youth's School

Student's Grade (Required)

Youth Name

Second Youth Attending

Age

School Name

Youth's School

Student's Grade

xk1atjz2ep6i

Youth Name

Third Youth Attending

Age

School Name

Youth's School

Student's Grade

Decedent's relationship to child(ren): (Required)

Decedent's relationship to child(ren):

If "Other", please detail here:

Is English the primary language spoken in the home?

If "No", what language is spoken?

Funding agencies often require nonprofit organizations to maintain client information related to gender, race, age, and income level. The requested information is strictly for the purpose of Mourning Hope's compliance with these record-keeping requirements. Responses will remain anonymous, and are greatly appreciated.

Race of Participant(s)

Total Household Income

My child receives free/reduced lunch at school:

How many people live in your household?

Signature (Required)

By typing your name in the signature box, you are giving consent to participate and possibly be photographed for promotional purposes. The term "electronic signature" means a method of signing an electronic message that identifies and authenticates a particular person as the source of the electronic message; and indicates such person's approval of the information contained in the electronic message.

Todays Date: (Required)