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Survivors of Suicide Loss Registration

Survivors of Suicide Loss Support Group Registration

To register for the Survivors of Suicide Loss Support Group, please complete theĀ Registration Form below.

  • You may attend as an individual or as a family.
  • School-aged children must be accompanied by an adult caregiver.
  • Children under the age of five (5) are not permitted to attend.
  • Children must be aware that the cause of death was suicide prior to attending.

Registration Form

First Name
Last Name
Address Line 1
Address Line 2
Postal Code
Cell Phone:
Preferred method of contact:
Name of the person who died:
Date of death (month/day/year):
Please confirm the cause of death:
Please confirm that all youth attending know and understand that the cause of death was suicide:
Decedent's relationship to you:
If "Other", please detail here:
What are you hoping to get from this group?
What is the most recent Mourning Hope group/program you attended?
(i.e. Family Group, Young Adult Group, Adult Group, Holiday Hope, Mourning in Motion, Spirit of Giving, etc. If none, write N/A.)
Reaction to the death
Please check any behaviors you have experienced since the death:
Have you experienced any other changes in your life:
Will you be attending with a child/children?
If "No" please scroll to the "Registering For" section. If "Yes" please complete information for each child.
First Youth Attending
Youth's School
Second Youth Attending
Youth's School
Third Youth Attending
Youth's School
Decedent's relationship to child(ren):
If "Other", please detail here:
Reaction to the loss
Please check any behaviors your child(ren)/teen(s) has/have exhibited since experiencing the death:
Registering for:
Name(s) of other adult(s) attending:
Is English the primary language spoken in the home?
Mourning Hope sessions typically include refreshments; please list any food allergies for participants:
Please list any mental or physical disabilities and accessibility needs for participants:
Do you (or anyone who will be attending) have a dog allergy?
Do you (or anyone who will be attending) have a fear of dogs?
(A companion dog, similar to a therapy dog, may attend the Survivors of Suicide Loss Support Group.)

Funding agencies often require nonprofit organizations to maintain client information related to gender, race, ageĀ 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.

My child receives free/reduced lunch at school:
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.