Registrant

First Name

Last Name

Mobile

Home

Address

Grieving loss of (please indicate relationship to you)

Do you have a home church?

Name of home church

Would you like to participate in GriefShare In-Person or via Zoom?

Do you have any other comments or information you would like to share?

I would like to pay for my workbook now. ($20.00)

I will pay for my workbook at the first GriefShare session.