More Than Words Champion Enquiry Form

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More Than Words Champion Enquiry Form

Please complete this form if you would like assistance in creating a peer-led support group for bereaved individuals in any of our target areas.
Cruse Bereavement Care, working with the British Red Cross can offer free training, advice, information and resources to help you get started! In some instances, limited funds may be available for initial group activities.

• Name:*First: Last:

• Age Banding:* ---Please Select--- 18-24 25-34 35-44 45-54 55-64 65+ Prefer not to say

• Gender: Prefer not to say Male Female Other

• Time Since Bereavement:* ---Please Select--- 0-3 Months 3-6 Months 6-9 Months 9-12 Months 1 Year + 2 Years + 5 Years + 10 Years + Prefer not to Say

• I would like help and training to set up a group in

* ---Please Select--- Bedfordshire (Luton) Birmingham (Sparkbrook) Leeds (Armley) Liverpool (Kirkdale) London (Hillingdon) Manchester (Rochdale) Newcastle (Byker and Walker) Nottingham (Lenton) Sheffield (Burngreave) Northern Ireland (Belfast) Scotland (Edinburgh) Wales (Cardiff)

• Are you interested in any of these activities?

Tea/Coffee & Cake

Arts & Crafts

Walking Groups

Museums/Galleries

Board Games

Fundraising

Other (please specify in Comments section below)

• E-Mail Address:*……………………………………….

• Phone Number: …………………………………

• How did you first hear about us?*

Cruse social media

Other (please specify below)

British Red Cross social media

GP/GP Surgery

Cruse website

Counsellor

Co-op social media

• Previous Experience (if any) - NOT ESSENTIAL –

• Comments & Queries:

• Please tick this box to indicate you have read and agree to ourData and Privacy Policy.Your data will be processed by Wufoo, details of their privacy and security measures can be foundhere
  

Yes, I understand

Please post the completed form (including postage) to More than Words, Cruse, Unit 0.1 Victoria Villas, Richmond, Surrey, TW9 2GW