Guiding Star Application

Application for Guiding Star

First name

Last name

Deceased Loved One's Name

Date of Birth

Date of Loss

Cause of Death

Name

Occupation

Relationship to bereaved

Organization

Phone

Mother's First & Last Name

Father's First & Last Name

Home Address

Home Phone

Cell Phone

Child #1 Name

Age

Relationship

Children Medical Conditions: Do any of these children have a medical or other concern or condition? If YES, please explain:

Family Medical Conditions: Does anyone else in your family have a medical condition we should be aware of?

Special Interests: Does anyone in your family have any special interests, talents, or hobbies?

Expectations: What are your expectations and/or hopes for your visit to Guiding Star?

Your Story: Please tell us your loved one's story. You may give as much detail as you wish.

By checking this box, I attest that all of the above information is true and complete to the best of my knowledge.

Thanks for submitting!