Authorization Form




Please read, complete and return to:

The Compassionate Friends of F-M Area
P.O.  Box 10686
Fargo ND 58106

OR - Email to: tcf1313@gmail.com

We are happy to send our newsletter to you. We hope that it is helpful to you to be kept informed of chapter resources and activities and that you still wish to receive our newsletters that contain excellent material relating to grief issues. To keep our mailing list current, we do ask to hear from you each year making sure that our information is correct and that you still wish to receive our mailings. If you wish to continue to receive our newsletter, please indicate any appropriate choices below and return the form to the address at the bottom of this page.

 

Your Name: _______________________________________________________________________________

Child's Name: _______________________________________ Relationship: ___________________________

Birth Date: _________________ Death Date: _______________ Cause of Death: ________________________

Address:__________________________________________________________________________________

City: ___________________________________________ State: ____________ Zip: ____________________

Home Telephone: __________________________________________________________________________

E-mail: ___________________________________________________________________________________

Please check any of following that apply.

__ Please continue sending the newsletter.

__ By mail.                   __ By email.

__ No thank you, I'd prefer to stop receiving the newsletter. (Newsletters are posted monthly on our Web site.)

We must have your written permission on file to use your child's name and/or picture in the newsletter, Web site or any other TCF event. Permission may be withdrawn at any time by written request. This information is used to maintain our Chapter Database. It is confidential and is only utilized for Chapter activities such as the newsletter.

____________________________________________________________________Date: ________________
(Signature)

 
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