Registration for in-person and online Bereavement Support Groups Please enable JavaScript in your browser to complete this form.Privacy and confidentialityBy registering, you agree to help protect the privacy and confidentiality of everyone in the group.For all participantsDo not record sessions or take screenshots.Keep other participants’ personal details private; do not share them outside the group.If you leave a session without notice, we may follow up with you by phone or email.For online sessionsJoin from a private location where others cannot hear the session.Do not have anyone present who has not completed an intake.Do not share the online group link.Liability Waiver for Journey Through LossThis waiver of liability includes any risk of attending in-person sessions, engaging in online sessions, or attending any events, or other bereavement support group services (“Services”) provided by Journey Through Loss (“JTL”). By agreeing to this waiver:You understand that JTL Services are not offered as a substitute for medical care and are not intended to diagnose or cure any mental health or medical conditions. Also, you understand that our facilitators are not acting as medical or mental health professionals.You understand and agree that you are fully responsible for your own well-being during your access to the Services, and you are responsible for making your own choices and decisions.You understand that the information you provide to us will be shared with other JTL facilitators. This information cannot be released without your informed and written consent, except:in circumstances where we have a duty to report child abuse and neglect,when there is a threat of harm to yourself or others, orwhen we are served with a court order.You understand that all comments and feedback offered by our facilitators are for the sole purpose of assisting you in achieving your goals. You will be able to give informed consent, and hereby give such consent to the facilitator(s) to assist you in achieving such goals.You understand that the use of technology is not always secure and accept the risks to confidentiality in the use of email, text, phone, online services and any other technology.You hereby release, waive, acquit and forever discharge JTL, including, but not limited to: JTL or its directors, volunteers, students, and their respective successors and representatives, from every claim, suit action, demand or right to compensation for damages claimed or that you may have arising out of your own acts or omissions or acts and omissions of JTL or its directors, volunteers, students, and their respective successors and representatives, as a result of any advice given otherwise resulting from the relationship contemplated by this agreement.By clicking “Submit” I acknowledge I have read and understand the provisions in this form and consent to same.Fill in the information below and click submit. We’ll be in touch as soon as possible with details to join the group.Name *FirstLastAddress *Address Line 1Address Line 2City— Select state —British ColumbiaOntarioQuebecAlbertaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutPrince Edward IslandSaskatchewanYukonProvinceCode PostalPhone *Voicemail ConsentI give permission to leave a voicemail if you’re unable to reach me.What time of day is best for us to contact you?MorningAfternoonEveningNo preferenceSelect all that work for you. We’ll do our best to contact you at a preferred time.Email *By clicking this Acknowledgement, you agree to adhere to the above guidelines and liability waiver to participate. *I Agree to the Following Guidelines and Liability WaiverIf you have NOT previously had a live intake telephone interview with a JTL facilitator, you will be contacted directly to complete the intake interview prior to your first scheduled online or in-person meeting.Intake Interview *I HAVE previously had a live intake telephone interview with a JTL facilitatorI HAVE NOT previously had a live intake telephone interview with a JTL facilitatorAs a registered member, you are able to attend either the online or in-person group. Please tell us how you would like to attend group initially.Group Preference *I would like to register for the in-person Bereavement Support GroupI would like to register for the online Bereavement Support Group Please tell us how you heard about us (e.g., online, another member, funding partner, healthcare professional, etc) * Online Group Please Note: While every attempt is made to assist individuals with registering to attend the online bereavement support group, it is expected that participants will be willing to download the necessary (free) software to their electronic device. This is a necessary requirement to gain accessibility to the online group.PhoneSubmit