Registration Form: Angel Moms Pregnancy Loss Support Group

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Angel Moms is a compassionate and culturally responsive grief support group for women of Color who have experienced pregnancy loss. This group provides a safe space that fosters hope, help and healing from the trauma of miscarriage, stillbirth, and early infant loss.

Dates: September 26 - November 7th

Tuesday Nights: 6:30 pm - 8:30 pm MST

Location: Aurora, CO

(the exact location will be given upon acceptance)

*This group is intended for commitment to attending all 7 sessions.

*Limited space for 12 participants*

Please provide the following information to register for this 7-week grief support group as we look forward to seeing you.

Email *

First Name *

Last Name *

First and Last Name of Father (optional)

Cell Phone *

Mailing Address:

Please list street number, City, State, Zip Code

Would you like to receive a greeting card in honor of your baby on anniversaries?

Yes

Type of Loss(es) Experienced *

Miscarriage

Stillbirth

Labor Complications

Early Infant Loss

Other:

Required

If Miscarriage or Stillbirth - What was the gestation period? How many weeks? *

Have you experienced multiple losses? *

Yes

If yes, how many losses have you personally experienced? Please explain: *

Baby's Gender

Male

Female

Unknown

Clear selection

Baby's due date (If known)

YYYY

Baby's birthday (If applicable)

YYYY

Baby's anniversary (date of loss):

YYYY

If you have more than one loss, please use this space to provide additional information:

1) Baby's first and last name (if known)

2) Baby's gender (boy or girl)

3) Baby's due date (if known)

4) Baby's anniversary (date of passing)

5) Gestation period

6) Type of loss

Have you received individual therapy or group counseling before concerning your loss(es)? *

Yes

Other:

Are you able to attend all 7 in-person sessions?

Tuesday Nights from 6:30 pm - 8:30 pm

(September 26 - November 7)

Yes

Please express any expectations you have for joining this grief support group:

What type of support are you interested in? (Check all that apply). *

Monthly Connection Activities

Awareness & Remembrance Events: Grief Walks, Balloon Releases, etc.

1:1 Compassion Calls: Initiated by AP Staff to Check-in with you.

Social Engagement: Encouragement and Connection on Instagram / Facebook

Required

How did you hear about this support group?

Photo Release. I give permission for my image to appear in pictures, photographs, electronic images, video, audio, any publications, on any website or other electronic media and for Adam's Purpose to share such images with this parties without payment or renumeration to either the Participant or the Parent or Legal Guardian. I understand that there may be photos & videos taken while participating or being in close proximity to Adam's Purpose Activities. Adam's Purpose, their partners and sponsors have my permission to use these photos on their social media sites and other other marketing materials. I understand that I can contact the company in writing if I would like a photo of myself removed within a reasonable amount of lead-time.

I Agree

By completing this form, you agree to your information being added to our subscriber database to receive updates about future events. Your privacy and preferences are important to us.

*You may unsubscribe at any time.

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