Heartstrings, Inc.

Subsequent Pregnancy Support Group Interest Form

Please fill out the following information in regards to yourself:

* First Name

* Last Name

* Email

* Birthdate

* Address

* City

* State

* Postal Code

* County of Residence

* Phone

Mobile Phone

* May we leave a message on your answering machine or voice mail?

* Would you prefer we contact you at...

* Marital Status

* Race/Ethnicity (for purposes of grant and donor funding)

* What is the due date of your current pregnancy?

* How far along are you in your current pregnancy (weeks/months)?

How did you find out about Heartstrings?

* Referral Type

* Referring Organization

* Referral Source

Referral Name

* Was this the first time you learned about Heartstrings?

* How did you learn about Heartstrings?

* When did you learn about Heartstrings?

Release of Information

I give my permission to release my (our) names, telephone number, and other relevant information to Heartstrings' Subsequent Pregnancy Support Group facilitator and necessary staff in order to arrange the services I have requested.

State of North Carolina Release and Waiver of Claims

I do hereby desire to participate in the Support Programs offered by Heartstrings® and any and all activities offered by Heartstrings in connection with the same.

In consideration of my participation in the Support Programs, I, on behalf of myself, my heirs, assignees and personal representatives, voluntarily and with knowledge, hereby assume any and all risk of accident or damages, physical or mental, to my person or my property which may be incurred from or be connected in any manner with my participation in the Support Programs. I further hereby release and forever discharge Heartstrings, its facilitators, volunteers, Board of Directors, employees, agents, members, sponsors, organizers, promoters, affiliates and other participants from any and all liability, claims, demands, actions, causes of action, loss, injuries, costs or expenses, including attorney's fees, that may arise from my participation in the Support Programs. I further waive and promise not to sue upon any claims, arising pursuant to statute or under common law against the Heartstrings, its facilitators, volunteers, Board of Directors, employees, agents, members, sponsors, organizers, promoters, affiliates and other participants, arising directly or indirectly from or attributable in any way to any negligence, action, omission or failure to act by any such person or organization with regard to any and all activities associated with the Support Programs.

I hereby assume full responsibility for and risk of bodily or emotional injury, death or property damage due to the acts, failure to act, negligence, conduct or intentional torts of Heartstrings, its facilitators, volunteers, Board of Directors, employees, agents, members, sponsors, organizers, promoters, affiliates and other participants, while on the premises of the same or while observing, working for or in any way participating in the above-described any and all activities associated with or offered in connection with the Support Programs.

I expressly acknowledge and agree that the activities of the above-described event may involve the risk of serious physical, emotional and/or psychological injury to myself and/or damage to my property. I further agree that the foregoing release and waiver is intended to be as broad and inclusive as is permitted by the laws of the State of North Carolina and that if any portion of it is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I have read and voluntarily sign this Release and Waiver of Liability and further agree that no oral representations, statements or inducements apart from the foregoing written agreement have been made.

I acknowledge and agree to the terms set forth above.

About Subsequent Pregnancy Support Groups

A subsequent pregnancy after the loss of a baby can bring forth many feelings ranging from anxiety, anger, sadness and fear to a sense of renewed hope, joy and excitement. During this time of heightened emotions, it can be helpful to talk with other mothers facing their own subsequent pregnancy with the purpose of sharing information, encouragement and hope.

Heartstrings Subsequent Pregnancy Support Group provides dedicated group support for mothers as they navigate their new pregnancy. Our Subsequent Pregnancy Support Groups are led by a bereaved parent who has gone through her own subsequent pregnancy and has assisted in the group’s curriculum development. The planned curriculum will focus on specific topics and themes for each session that participants will be able to prepare for in advance.

Modeled after The Heartstrings Method©, each cycle of our Subsequent Pregnancy Support Group meets for eight (8) sessions over a four (4) month period. Meetings are held on the first and third Monday of each month, from 6:30pm – 8:00pm at Heartstrings’ office in Kernersville. Up to three group cycles will be offered each year.

Subsequent Pregnancy Support Groups are open groups, available to women at any point during their pregnancy. Throughout this experience, participants will have the opportunity to meet other expectant women, receive specific education from scheduled guest speakers and discuss their concerns and joys in a safe, supportive environment.