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Oceans Grief & Loss
Social Justice Advocacy
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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

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Name*
First Last
Age*
Gender*
Address
Street Address City Postcode
Email Address*
Contact Phone*
Mobile
Ethnicity

Medical Conditions
Do you have any medical conditions?
Please note any medical condition we need to know about: eg food allergies; asthma; epilepsy
Tell us about your loss.
When did the loss occur?*
Please tell us about your loss*

Session Times
Please select your preferred day/s for the weekly meeting
1st Choice
2nd Choice
3rd Choice
Preferred time
Preferred Venue
How did you hear about the Oceans Programme?
Other
Other comment/s
Consent & Agreement*
I understand and agree to the following
I 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

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