OCEANS - GRIEF AND LOSS PEER SUPPORT PROGRAMME Adult Enrolment Finding hope and healing after loss starts here. Complete the form (online or download the PDF) below. Download Enrolment Form Enrol Online Step 1 of 3 33% Name* First Last Age*Gender*Address Street Address City Postcode Email Address* Contact Phone*MobileEthnicity Medical ConditionsDo you have any medical conditions?NoYesPlease note any medical condition we need to know about: eg food allergies; asthma; epilepsyTell us about your loss.When did the loss occur?*Please tell us about your loss* Session TimesPlease select your preferred day/s for the weekly meeting1st ChoiceAny day suitsMondayTuesdayWednesdayThursday2nd ChoiceMondayTuesdayWednesdayThursday3rd ChoiceMondayTuesdayWednesdayThursdayPreferred timeAny time suitsDuring daylight hoursAt night timePreferred VenueSelect VenueAshburtonGeraldineTemukaTimaruWaimateOnline (ZOOM)How did you hear about the Oceans Programme?WebsiteWord of mouthFrom a friendOtherOtherOther comment/sConsent & Agreement* I understand and agree to the followingI understand and agree that the Oceans Grief and Loss programme is supported by Christchurch City Mission: ● Will treat my information with security by the programme coordinator and only share information with programme facilitators to enhance the relevancy and support of the programme. ● The City Mission will retain clients’ personal information no longer than it is required for the purposes for which the information was collected. ● May use my information in a way that does not identify me for statistical or audit purposes. ● Cannot guarantee confidentiality when my personal safety, the safety of others or the safety of the participant are in question. I can request at any time: ● T o view information the Oceans Grief and Loss programme holds about me. ● T o give feedback on Oceans Grief and Loss programme services.To assist in covering the cost of the OCEANS Programme and to confirm your attendance, we would appreciate a payment of $20.00. Our ANZ bank account number is: 06-0831-0007713-51