First Name: *

Last Name: *

Address: *

City: *

State: *

Zip Code: *

Country: *

Daytime Phone:

Evening Phone:

Mobile Phone: *

Your Email: *

Your Age:

I lost my (relationship):

Name(s), Age(s) of Loved One(s):

I survived an air disaster

Air Carrier/Flight Number:

Location of Incident:

Date of Incident:

Departure City:

Destination City:

I'm able to volunteer via (check all that apply):
Phone
Email
Post

Contact Me:
Contact me by phone
Contact me by Email

Best time to contact you?:

How did you hear about ACCESS?:

Do you have children or other dependents? (Please list their names and ages):

Your Occupation:

Your Special Interests:

Are you involved in any air disaster groups? If so, which ones?

Have you created Memorials for your loved ones? If so, please describe:

Profile

Please include as much information as possible about your unique experience to help us better match you to an individual in need. (For example: your methods of coping and your reactions to the disaster are especially helpful to us)
If you prefer to follow a framework there are some suggestions below. These are only guidelines and you should feel free to elaborate.

Please describe your loved ones relationship to you and a brief background about them -- profession, age, hobbies, anything else that you consider to be of importance in order to describe them:

How did you learn of the disaster? Could the information have been relayed better? Was the timing and method appropriate?

What helped you the most in getting through the first hours, days, weeks and years following your loss?

Who have you turned to for support? (Other victims, family members, counselors, people of faith) How have they helped you?

What have been the most difficult roadblocks in your journey and how have you overcome them?

What comments, words or phrases did people say to you that were helpful following your loss? Which were hurtful?

What do you know now that you were not previously aware of that would have helped you following your loss?

What do you think would be the most helpful advice to give someone who has just lost a loved one?

Anything else you would like to share?

I have read and agreed to the Terms of Volunteer Grief Mentoring