Survivors of Suicide Support Group - Member Data Sheet Date Name Full Address Phone Number Is it ok for a staff member to contact you by phone? Yes No # of people in household Loved One's Name / Relationship to You Their Dates of Birth / Death Email Address Is it ok to share your email address with the facilitator to be invited to the private, online SOS group? Yes No Would you like to receive the monthly e-newsletter from the Eastern Missouri Chapter of the American Foundation for Suicide Prevention (AFSP)? Yes No Would you be interested in receiving cards via mail from LCS Staff members near anniversary dates or birthdays of your lost loved one? Yes No Gender Male Female My race/ethnicity is Caucasian African-American Hispanic Asian Native American Other Age Under 18 18-24 25-34 35-44 45-54 55-64 65 or Above Prefer Not to Answer
