REGISTRATION FORM

    Grieving...Between The Rock and a Hard Place
    October 7-9, 2016

    Name   Phone
    Address   email

    Emergency Contact   Relationship
    Phone #1   Phone #2

    Name, age, & relationship of any additional people coming with you:
    (If you are not legal custodial parent or guardian, please bring signed statement by legal parent/guardian that they give permission for their child to attend.)
     
    Name and relationship to loved one(s) you have lost, and date of death:
     
    How did you hear about The Consoling Place
     

      (When you submit your registration, you will be taken to a page
      through which you can pay the required $50 per person registration fee. )

     


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