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Intl Survivor of Suicide Day 2014 RSVP for Illinois
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Full Name:
(Example: Rachelle Jervis, MBA)
(Required.)
*
Email Address:
(Example: illinois@AFSP.org)
(Required.)
*
Mailing Address:
(Example: AFSP, 2906 Central St, #293, Evanston, IL 60201)
(Required.)
*
Which Int'l Survivor of Suicide Day Event Location Site Are You RSVPing to Attend?
(Required.)
Arlington Heights, IL @ Alexian Center, 3436 N Kennicott, Arlington Heights, IL 60005
Belleville, IL @ Heartlinks Grief Center, Family Hospice, 5110 W Main St., Belleville, IL 62226
Belleville, IL @ Karla Smith Foundation Location, Peace Chapel, 10101 W Main St., Belleville, IL 62269
Dixon, IL (Sauk Valley) @ Sinnissippi Centers, Dixon office - Training Center, 325 Illinois Route 2, Dixon, IL 61021
Machesney Park, IL (Rockford Area) @ Riverside Community Church, 6816 N 2nd St., Machesney Park, IL 61115
Naperville, IL @ Fox Valley Institute, 640 N. River Rd., Suite 108, Naperville, IL 60563
Peru, IL @ Illinois Valley Community Hospital's Community Room in the Peru Mall, 3940 Route 251, Suite E-1, Community Room, Peru, IL 61354
Springfield, IL @ Lincoln Prairie Behavioral Health Center, 5230 S. 6th Street Road, Conference Room, Springfield, IL 62703
Woodstock, IL @ Resurrection Catholic Church, 2918 S. Country Club Rd, Woodstock, IL 60098 (South of Loyola's Retreat & Ecology Center)
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Type of Loss(es):
(Required.)
Husband
Wife
Partner
Boyfriend
Girlfriend
Daughter
Son
Step Daughter
Step Son
Grand Daughter
Grand Son
God Daughter
God Son
Mother
Father
Grandmother
Grandfather
Brother
Sister
Twin Brother
Twin Sister
Aunt
Uncle
Cousin
Friend
Classmate
Colleague
Neighbor
Student
Teacher/Educator/Professor/Mentor
Other (please specify)
*
Date of Loss(es):
(Example: January 1, 2000)
(Required.)
*
Names of any additional people in group you are also RSVPing for:
(Please include their relationship to the individual you have lost. Also please provide their email address so we can send them an event reminder.)
(Required.)
No
Yes. Please list their name(s), email address(es), and relationship to the loss.
*
Have you attended AFSP's International Survivor of Suicide Day Event before?
(Required.)
Yes, In Person
Yes, online
No
*
What is your level of AFSP involvement:
(Please mark all that apply)
(Required.)
This is the first AFSP event I will be attending
I have attended an AFSP event before
I am interested in volunteering for AFSP
I have walked in an Out of the Darkness Community or Campus Walk in Illinois
I have donated to support an Out of the Darkness Community or Campus Walk in Illinois
I currently (or in the past) volunteered for AFSP
I would like to receive the monthly AFSP Illinois enewsletter
I currently receive the monthly AFSP Illinois enewsletter
Other (please specify)
*
How did you hear about this event?
(Required.)
AFSP Newsletter (Sent by Email)
AFSP Website
Facebook AFSP Page
Hospital Referral
LOSS Newsletter
Mental Health Professional Referral
Newspaper
Out of the Darkness Community Walk
PSA on Radio
Referred by Friend
Search Engine
Support Group Referral
TV Coverage
Twitter (@AFSPIL @AFSPChicago or @AFSPNational)
Other (please specify)
*
Are you a mental health professional?
(Required.)
Yes
No
Other (please specify)
Is there any additional information you would like us to have?
