Registration Form

Registration Form

Kindly fill out this form to complete your registration.

Name*
First Name:
Last Name:
Address: You must reside in Tompkins or Cortland County to participate.*
Street Address:
Street Address Line 2:
City:
State / Province:
Postal / Zip Code:
County of residence?*:
Email:
Phone Number:
Please select the session you would like to attend. You may only choose one and you must attend that same session for all five weeks. Both sessions are on Tuesday, October 7, 14, 21, 28 and November 4*:
Did your loved one die on Hospicare services?:
How did you hear about the workshop?:
Statement of Confidentiality An integral part of the quality of bereavement service that Hospicare offers in a support group setting is absolute confidentiality. Revealing information that is shared in a bereavement support group is prohibited, even in the strictest of confidence, to a close friend, family member, or others. When participating in an online support group, we ask that you consider confidentiality by finding a private location to participate in the meeting, using headphones and turning the monitor away from anyone in the vicinity.
By checking this box and typing my name below, I am electronically signing my name and confirming that I have read and understand the above Statement of Confidentiality, and I agree to abide by the guidelines set forth.:
Name:
Date:
When you click "submit" a registration confirmation will automatically be sent to your email. It sometimes lands in spam folders, so please look for it there if you do not receive it.