Grief Recovery Registration Form

Grief Recovery

Grief Recovery Workshop

Name*

Address*

Apt

City*

State*

Zip*

Phone*

() -

Email*

Gender*

Male
Female

I have experienced the loss of: (spouse, child, friend)*

Early Registration = $20 (Couples $30)

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(Before January 11, 2012)

Registration = $25 (Couples $35)

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(After January 11, 2012)

How did you hear about this workshop?*

5455 Market Ave N.
Canton, OH 44714
330-966-2800