Mental Health America of Wisconsin

Programs & Services > Survivors Helping Survivors > Survivors of Suicide Loss Day > Registration:

Survivors of Suicide Loss Day

Registration

Please complete the following. A confirmation will be sent to the email address provided below. If you have questions or need additional information, please contact Leah Rolando at leahr@mhawisconsin.org or 414-336-7970.

First name:

Last name:

Email:

Phone:

If you are attending as a family or group, first and last name of everyone attending:
*

Are you a survivor of suicide loss?

Yes

Who did you lose to suicide (ex: child, friend, spouse, sibling, etc.):

When did you experience this loss?

Would you like to register for the painting session?

Yes

If you are registering as a family or group, names of those you are registering for the painting session:
*

5 + 8 = Solve This To Prove You are a Real Person, not a SPAM script.