Collierville Survivors' Forum
A step towards healing for those present at Kroger on Sept. 23rd

Central Church, 2005 E Winchester, Fellowship Hall - enter at West Entrance, back door
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Pre-Registration for Survivors
The Shelby County Crime Victims & Rape Crisis Center (CVRCC) is hosting a Survivors' Forum for all people present at the 9/23 Kroger tragedy.  The goals of this forum are to connect survivors to help create informal networks of support, as well as provide education on the impact of trauma and explore coping skills that can help decrease that impact and promote healing.  This forum will not be a processing session, but we will be connecting people with resources and support for follow up services.  

Attendance will be limited for this forum to only the people directly impacted (those in the store or parking lot) and their primary support people in order to create a safe space for healing discussions.  

Please fill out this registration form completely to help us better understand who will attend the forum.  

All information collected in this form will be kept confidential by the CVRCC, unless you give us permission to share with other agencies.  

Representatives from Kroger, the Town of Collierville, and the Collierville Police Department will join us briefly at the beginning of the forum only.  The remaining time of the program will be focused solely on trauma recovery.  

There will be no media present, and only those who were directly impacted (and their support person) will be allowed in the forum.  We will be checking picture IDs at the door to ensure safety for all.    
   
First Name *
Last Name *
Best Contact Phone Number *
Best Contact Email Address *
Were you inside the Byhalia Kroger, or in the parking lot, on Thursday, September 23rd at ~1:30pm? *
Are you a Kroger Employee or a shopper/contractor?
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Have you provided a statement regarding the incident to the Collierville Police Department?   *
If you haven't provided a statement yet, would you want CVRCC to share ONLY your name and phone number with Collierville Police Department to facilitate a statement?   *
Sometimes it's helpful to have supportive people in your life attend events like these so they can also learn how to better support you.  If you choose to bring 1-2 support people, please list their names here. *
Do you have any other specific questions or concerns that you would like to tell us about?   *
Submit
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