Highland-Markham Chapel Intake Form

Highland Funeral Home – Markham Chapel

Funeral Director *

Name of Deceased *

First

Last

Primary Contact Name For Next of Kin (Client) *

First

Last

Next of Kin Phone Number

Next of Kin Email Address *

Services Required *

Location Email Interment

Comments, Questions or Special Requests

Consent Authorization *

I, herby, authorize and provide my consent for VLC Productions Inc. to use my name, email, phone number, and other relevant contact information for the purpose of delivering the requested production services, and to contact the client ("Next of Kin") as needed for the purposes selected above.