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Thank you for your interest in joining Yoga to Cope's "Death Club." Note a facilitator may reach out to ensure this space is an appropriate fit for your needs.

Please note this is a non-clinical support group hosted by educational nonprofit organization Yoga to Cope. Confidentiality is a priority, though sessions will not be HIPAA-compliant. All participants must acknowledge and uphold the organization's confidentiality and community agreements to ensure the safety of all members. Any violation of such will be cause for immediate removal from future group sessions.  

Please reach out to hello@yogatocope.org with any questions, comments, or concerns. 


First Participant's Name
First Name*
Middle Name
Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information
Additional Name + Pronunciation Info:
Pronouns:
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Additional Name + Pronunciation Info:
Pronouns:
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Additional Name + Pronunciation Info:
Pronouns:
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Additional Name + Pronunciation Info:
Pronouns:
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Additional Name + Pronunciation Info:
Pronouns:
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Additional Name + Pronunciation Info:
Pronouns:
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Additional Name + Pronunciation Info:
Pronouns:
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Additional Name + Pronunciation Info:
Pronouns:
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Additional Name + Pronunciation Info:
Pronouns:
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Additional Name + Pronunciation Info:
Pronouns:
Parent or Guardian's Email Address
Email*
Confirm Email*
General Questions

Please provide and information relevant to the above question: 

Please share any specific areas of interest, curiosities, and/or questions related to Death Club:
Are you currently experiencing grief/loss? If yes, please provide any additional information to your comfort level.
Support Needs
Do you have any accessibility needs or accommodations?
Is there anything you would like the facilitator to know ahead of time?
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
Additional Name + Pronunciation Info:
Pronouns:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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