Grief and Grub for Guys Registration
Example Registration Email
Grief and Grub for Guys registration request
Name: Shea Zsombor
Email: szsombor@hospiceprincegeorge.ca
Address: 1506 Ferry Avenue
City: Prince George
Province: BC
Postal Code: V2L 5H2
Phone: 2505632551
Age: 32
Medication, Health, or Allergy Concerns: Lactose Intolerant
Name of Person who Died: Name of deceased
Relationship to Participant: Relationship to deceased
Date of Death: Feb 20th
Do you have family and/or friends who are able to support you at this time? Yes, Friends and family.
Broken Circle Registration Request
Example Registration Email
Broken Circle registration request
Name: Shea Zsombor
Email: szsombor@hospiceprincegeorge.ca
Address: 1506 Ferry Avenue
City: Prince George
Province: BC
Postal Code: V2L 5H2
Phone: 2505632551
Age: 32
Medication, Health, or Allergy Concerns: None
Name of Person who Died: Deceased Name
Relationship to Participant: Relationship to Deceased Date of Death: February 21st 2020
Have you had previous counseling regarding your loss? None
Do you have family and/or friends who are able to support you at this time? Yes, Family and friends
Rainbows Children's Grief Program Registration Request
Example Registration Email
Rainbows Children’s Grief Program Registration Request
Child’s Name: Jane Doe
Child’s Gender: Female
Child’s Age: 12
Child’s Birth Date: Jan 4th, 2008
Grade: 6
School: Austin Road
Address: 1506 Ferry Avenue
City: Prince George
Province: BC
Postal Code: V2L5H2
Phone: 2505632551
Parent / Guardian Name: John Doe
Relationship to Child: Father
Email: registration@hospiceprincegeorge.ca
Siblings living with child: Billy Joe Doe, 15, No Mary Jane Doe, 9, Yes
Description of Loss(es): Death of mother Specified loss:
When did the loss occur: Last November, 2019 Any additional major losses within the last year: No Notes on additional losses:
Attending or has attended counselling?: Attended Any medication, health, or allergy concerns?: Peanut allergy
Emergency Contact Information
Contact Name: Johnathan Doe
Contact Phone: 2505555555
Contact Relationship: Grandfather
Consent: As legal guardian, I give consent for my child to participate in the Rainbows support program at the Prince George Hospice Society Beveavement Centre.