Please print, filling in all applicable blanks/boxes:
Your Name: _______________________ Mailing Address: ___________________________
City:___________________________ State: _________ ZIP Code: ____________________
Phone (including area code):________________ Email:______________________________
Do you prefer to receive the newsletter by (check one): Mail_____ Email ______
Child’s Full Name:____________________________ Male: ________ Female ______
Child’s Birth Date: _____________ Child’s Remembrance Date:______________
Cause of Child’s Death (optional):___________________________________________
Child’s relationship to you (e.g. son, daughter, brother, sister, grandchild)
Names and ages of all surviving siblings living with you:
_____________________________________ _____________________________________
_____________________________________ _____________________________________
*How did you find out about The Compassionate Friends? Please circle one:
Family, Friends, Hospital, Church, School, Funeral Homes, Internet, Newspaper, Employer (Human Resources) or Other
Note: The information you have given above will be confidential (used for internal purpose only) unless you answer “yes” to one or more of the following questions:
1. Do you want your child’s name to appear in the newsletter’s “Our Children Loved and Remembered” section of birth and remembrance dates? Yes ___ No ___
2. Do you want your phone number given to another member for one on one support, otherwise known as Telephone Friends? Yes___ No___
3. Do you wish to have your child’s name included on the Wall of Memory on out TCF Fredericksburg Web Site? (This is currently in the process of being put together) Yes___ No___
Voluntary donations are TCF Fredericksburg Chapter’s only source of income. The Compassionate Friends needs to be here for the families who do not know today that they will need us tomorrow.
Yes, I want to help with TCF Outreach…a donation is enclosed in Memory of ___________________________________________________
I would like to apply my donation toward the following outreach:
Newsletter ___ (recommended amount for paper newsletter is $15.00 which would go towards postage, paper and copying) Library ___ General Expenses ___ Birthday/Remembrance Date Cards ___ Newly Bereaved Packets ___ Annual Candlelight Remembrance Service ___
Make Checks Payable to: The Compassionate FriendsPlease Return To: The Compassionate Friends, Fredericksburg Chapter, P. O. Box 172, King George, VA 22485
