Date Beyond Grief - A Night Out for Bereaved Parents Registration

First Name *

Last Name *

Spouse's Full Name *

Phone *

Email *

Child's Name *

Date of Death *

Age at Death *

Cause of Death

Please share add'l deceased children's information if applicable.

Address *

City *

State *

Postal code *

If other, Please explain:

Any food allergies? *

Yes

If yes, please list allergies.

Signature *

Clear

By signing my name, I hereby grant permission to BeReAVEd Together, Inc. to use my image (photo/video) for use in media publications including video/print marketing, advertisement, public website, and social media platforms, and waive any rights to inspect or approve the photos/electronic matter that may be used in conjunction with them now and in the future. I waive any right to royalties or other compensation. I confirm that I am 21 years of age or older. I have read this release and fully understand the contents, meaning, and impact of this release. I understand that I am free to address any specific questions regarding this release prior to signing and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. I understand that BeReAVEd Together, Inc. includes some physical activity, emotional wellness, mental health hygiene, and spiritually-based curriculum. As is the case with any activity, there is risk of injury. I hereby release any responsibility from BeReAVEd Together, Inc. and assume full responsibility for any injury, and all damages, which may incur through participation. The classes, curriculum, workshops and/or events facilitated by BeReAVEd Together, Inc. are not a substitute for professional therapy, medical/clinical treatment for any physical, mental, emotional, or spiritual care. By signing, I affirm that I am willing to participate in the hosted event by BeReAVEd Together, Inc. In addition, I will make any presenter/instructor aware of any medical or mental conditions or limitations before participating or engaging in any activity. My signature verifies that I affirm that I alone am responsible to decide whether to practice and participate at my own risk and hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against BeReAVEd Together, Inc., its directors, team members, speakers, presenters, volunteers, contractors, or the like.

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from Bereaved Together. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.