The Aliver Foundation - Healing Hearts Program

Survivors and Loved Ones,  

Navigating life after sudden cardiac arrest with no roadmap is very difficult for survivors and their loved ones. While both experiences are very unique, the need to be heard is often the same. We listened and are happy to launch our Healing Hearts monthly support group program.

1) Please fill out this entire form to be participate in these free online groups.

2) We will then send you our confidentiality agreement.

3) Once you return the signed confidentiality agreement, you will then receive calendar invitations for our monthly groups.

Thank you.
-The Aliver Foundation
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Email *
First Name *
Last Name *
State (for example: New Jersey) *
Phone Number *
How would you define yourself? *
When was your or your loved one's cardiac arrest? *
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DD
/
YYYY
Do you acknowledge this program is not meant to be medical advice but rather a peer support group? *

Do you hereby release and forever discharge and hold harmless The Aliver Foundation and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, that arise or may hereafter arise from participation in The Aliver Foundation's Healing Hearts program?

IT IS UNDERSTAND THAT BY INDICATING "YES" THIS DISCHARGES THE ALIVER FOUNDATION FROM ANY LIABILITY OR CLAIM THAT YOU MAY HAVE AGAINST THE ALIVER FOUNDATION WITH RESPECT TO ANY BODILY INJURY, PERSONAL INJURY, ILLNESS, DEATH, OR PROPERTY DAMAGE THAT MAY RESULT FROM PARTICIPATION IN THE ALIVER FOUNDATION'S HEART-TO-HEART PROGRAM, WHETHER CAUSED BY THE NEGLIGENCE OF THE ALIVER FOUNDATION OR ITS OFFICERS, BOARD OF DIRECTORS, ADVISORY COUNCIL, AMBASSADORS, OR AGENTS OR OTHERWISE. YOU ALSO UNDERSTANDS THAT THE ALIVER FOUNDATION DOES NOT ASSUME ANY RESPONSIBILITY FOR OR OBLIGATION TO PROVIDE FINANCIAL ASSISTANCE OR OTHER ASSISTANCE, INCLUDING BUT NOT LIMITED TO MEDICAL, HEALTH, OR DISABILITY INSURANCE IN THE EVENT OF INJURY OR ILLNESS.

 *

Please type your first and last name, acknowledging your answer to the release question above. Please note that prior to participating, you will be asked to sign a confidentiality agreement to ensure what is said in the support group stays in the support group.

 *
A copy of your responses will be emailed to the address you provided.
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