Camp and Club Courage Email List Request

Camp and Club Courage Email List Request

Thank you so much for your interest in joining us for Camp or Club Courage!

Acknowledgement*

I understand that by filling out this form, I am consenting to receive emails about Hendrick Hospice Care's children bereavement programs.

I understand that submitting this form does not guarantee acceptance to our programs nor does it obligate your child to attend.

Parent/Guardian Name*

Phone Number*

Email Address*

Name of Child #1*

Age of Child #1*

2. Do you have another child to add?*

Select or enter value

Name of Child #2*

Age of Child #2*

3. Do you have another child to add?*

Select or enter value

Name of Child #3*

Age of Child #3*

4. Do you have another child to add?*

Select or enter value

Name of Child #4*

Age of Child #4*

5. Do you have another child to add?*

Select or enter value

Name of Child #5*

Age of Child #5*

Type of Loss*

Select or enter value

Please explain:

Which program(s) are you interested in?*

Select or enter value

Do you have any questions/concerns at this time?

Send me a copy of my responses