Give us a break!

Group Nomination Form

Telephone Number:
1st Facilitator:
2nd Facilitator:
Estimated dates of group running from:
Estimated dates of group running to:
Location of group:
Group numbers:
Age range within group from:
Age range within group to:

Please indicate the number of children who have been affected by each of the following

Bereavement of family member:
Bereavement of a friend:
Death of a pet:
Parental break-up:
Sibling separation:
Affected by cancer:
Other. Please give details: