Name of Organization

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* 1. Name of Organization

Where are you located (city, state)?

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* 2. Where are you located (city, state)?

Date Completed

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* 3. Date Completed

Total Number of bereaved children served annually in 2013?

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* 4. Total Number of bereaved children served annually in 2013?

What percentage of current bereaved youth served is represented by each of the following Racial/Ethnic groups?

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* 5. What percentage of current bereaved youth served is represented by each of the following Racial/Ethnic groups?

What percentage the children and teens you serve reside in the following areas?

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* 6. What percentage the children and teens you serve reside in the following areas?

What percentage of the bereaved families you serve fall into each income level?

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* 7. What percentage of the bereaved families you serve fall into each income level?

How many volunteers do you have?

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* 8. How many volunteers do you have?

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