Pre Planning Survey It would help us greatly if you would answer the questions on this survey. Your answers will help determine where our future time and resources need to be focused. All answers will remain confidential. 1 Survey2 Contact Info 1. What is your age group?Under 2526-4041-6566 or older2. Have you ever made funeral arrangements for a loved one?YesNo3. If yes, did you choose the funeral home because…Reputation in the communityOur family has used this funeral home beforeNewspaper/Phone bookComparative Pricing4. Do you own cemetery property?YesNo5. Where do you read the obituary information?NewspaperFuneral Home WebsiteNewspaper Online6. Would information on donating your organs be of value to you?YesNo7. If you have lost a loved one, would a follow-up visit (after the service) about extended programs available be of value to you?YesNo8. Is Advanced Funeral Planning something that:You’ve heard aboutYou have consideredYou would like to know more aboutOther family members have done9. Are your loved ones aware of your funeral preferences?YesNo10. If you had to decide today, which would you select:Anatomical DonationMemorial ServiceFuneral service with a casketGraveside Only11. To offer you the most in personalization, please indicate which of the following you would be interested in for yourself or a family member: (Check items of interest)Balloon ReleaseDove ReleaseEvening ServicesPatriotic ThemeMulti-Media Presentation (Slides, Video, ect)Service in a unique locationCelebration of Life Service (Music, Speakers)12. I would be interested in receiving more information on preplanningYes, Please CallYes, Please MailYes, Please EmailWould like to meet at Funeral HomeNo13. Advance Funeral Planning is available for everyone regardless of age or situation. Your wishes and preferences can be recorded and payments can be arranged to guarantee current prices. Pre-payments can be made in full or can be extended for as long as needed to accommodate you and your family. There’s no cost or obligation for inquiring and we encourage everyone to learn the facts and benefits of preplanning. Would you like to learn more about how this can work for you?YesNo - Not at this time Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhoneEmail NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.