3736 South Lee’s Summit Road
Independence, Missouri 64055

Office Phone: (816) 373-2600
Fax: (816) 373-3816
Emergency After Hours Number: (816) 507-1209

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Grief Recovery Registration Form

- Ministries

Grief Recovery^® Method
Information Sheet

The fee for this 8-week program is $50.00
$25.00 of that is non-refundable and is due with registration
$25.00 is due before the first session

Session Begins on, Tuesday, May 7, 2019
7:00 p.m. to 8:30 p.m.
Park in south lot
We will meet in meeting room 1 of the parish center
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- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Email Please enter an email address.
- Please try to answer the questions below.
  (Your ansewers will be kept confidential)
- 1. Have you ever belonged to a grief related support group? REQUIRED Please fill out this field.
- If yes, please name the group(s) that you have attended. Please enter valid data.
- 2. If you answered "yes" to question one, what did you like most about the group? Please enter valid data.
- What did you like least? Please enter valid data.
- 3. Please write down the loss(es) you have experienced. REQUIRED Please fill out this field. Please enter valid data.
- Which loss has bothered you the most? REQUIRED Please fill out this field. Please enter valid data.
- 4. My first experience with loss was the loss of? REQUIRED Please fill out this field. Please enter valid data.
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