Grief Support Interest Form
Please complete this form if you are interested in Grief Support at Gilda's Club Grand Rapids or our Lowell Clubhouse. A member of our program staff will contact you with more information. If you have any questions please call us at 616-453-8300 or email us at
to download a form to mail in or fill out the form below.
Date of Birth
Address Line 2
Postal / Zip Code
Male or Female?
Please email me the calendar monthly
work phone - optional
Employer (if any)
How did you hear about Gilda's Club?
Do you wish to receive information about donating to Gilda's Club, fundraising events and activities?
Your Grief Journey
Who in your life died?
When did the death occur?
Cause of death; if cancer, what type?
Are you interested in enrolling a child in the Children's Grief Program?
If yes, what are the children’s names, ages and who in their life died?
Emergency Contact Information
Emergency Contact Name
Do Not Fill This Out