New or Updated Member Information Form
We like to periodically update our membership and mailing list. Please complete the form below to ensure that we have your most up-to-date information.

This information is used for The Compassionate Friends RVA chapter business and event notification only. It is never shared or made public. Feel free to contact us at if you have questions. 

Today's Date
Member Information

Your First Name
Your Last Name

Street Address
Address 2
Zip Code
Lost Loved One*

First Name (or Nick Name)
Last Name
Age at Death
Birth Month
Birth Day

Month of Death
Day of Death

Cause of Death (optional)
My relationship to lost loved one
Child's Other Parents
Other Parent - First Name (optional)
Other Parent - Last Name (optional)
If you have remarried (optional):

New Spouse or Partner - First Name
New Spouse or Partner - Last Name
Newsletter Sign-up

Do you want to receive our newsletter? Yes   No   
May we include your child in the
Children Remembered list?
Yes   No   
Other Comments

At any time, if you would like to be removed from mailing list/member list, please send an email to: and put "Remove" in the subject line.


Copyright 2016 by The Compassionate Friends RVA