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Organisation's Details
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Step
1
of 4
Section 1 - Organisation's Details
Name
*
Occupation
*
Organisation
*
Contact Phone No.
Next
Section 2 - Child's Details
Family Name
*
Family Email Address OR Contact Details
*
In Memory of
*
Child's Age
*
Cause of death
*
Date of death
*
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Section 3 - Siblings Details
Number of Siblings
1
2
3
4
5
6
7
8
Siblings Name
Siblings Age
Siblings Name
Siblings Age
Siblings Name
Siblings Age
Siblings Name
Siblings Age
Siblings Name
Siblings Age
Siblings Name
Siblings Age
Siblings Name
Siblings Age
Siblings Name
Siblings Age
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Section 4 - Data Capture
I would like:
*
The Harvey Hext Trust to forward the application form to the family
to fill out the application form on behalf of the family
I have the families permission to pass their details to The Harvey Hext Trust
*
Yes
No
If you select 'No' we will be unable to proceed with this referral.
The Harvey Hext Trust may contact this family in relation to bereavement support
*
Yes
No
If you select 'No' we will be unable to proceed with this referral.
Please send me information on your free Siblings Bereavement books
Yes
Additional Comments
We will treat your personal data in accordance with our privacy policy.
Our Privacy Policy
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