Newsletter/New Member

To have your name added to the newsletter mailing list or become new member, please fill out the Newsletter/New Member Form 

New Member Information

Information is strictly Confidential and will be used in the creation & mailing of newsletter and to inform members
of Special Events, Meetings Etc…

Date
Last Name
First Name
Spouse
Street Address
City
State
Zip Code
Home Phone
Cell Phone
Email Address
Relationship to Child
(Parent, Grandparent Sibling, Etc)
Child’s Full Name
  Boy    Girl                 Age
Date of Birth
Date of Death
Cause of Death
Surviving Siblings Names & Ages
Please add my name to the newsletter mailing list Yes   No   
Include my child in the “Our Children Remembered” section of the Newsletter Yes   No   
Include my child in the future “Our Children Remembered” section of the Website Yes   No   
How did you hear about us ?

Information contained in this form is confidential and will be used as indicated above for chapter newsletter and or website and in the chapter database contact information. I give The Compassionate Friends, Lehigh Valley Chapter permission to use information as indicated. Permissions may withdrawn or added at any time by written request.

Signature