Grief and Grub for Guys Registration

14 + 7 =

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

11 + 4 =

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

Description of Loss(es)

Has your child experienced any additional major losses within the last year?

Attending or has attended counselling?

Consent

6 + 4 =

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.