College Protection Plan Form

Consultation Request

Please complete and return this planning worksheet by clicking the SUBMIT button at the end. Upon receipt, we will contact you to schedule your consultation appointment. We request that you be as thorough as possible and look forward to seeing you!
Name(Required)
MM slash DD slash YYYY
Are you a U.S. Citizen?(Required)
Address(Required)
Do you have any disabilities, serious health problems, or other special needs?(Required)
Financial Decision Makers (name, address, phone number, and relationship to you):(Required)
After you (and your spouse if applicable) have passed, who do you want making decisions regarding the management and distribution of your assets to your beneficiaries? PLEASE LIST THREE PERSONS IN THE ORDER THEY WOULD SERVE.
Health care decision makers (name, address, phone number, and relationship to you):(Required)
If you were unable to make decisions for yourself, who would you want to make decisions for you with regard to your medical treatment? PLEASE LIST THREE PERSONS IN THE ORDER THEY WOULD SERVE.
Do you want to provide that the moment of your death not be unnecessarily prolonged by artificial means or measures?(Required)
Do you want to provide that your vital organs be made available for transplant purposes?(Required)
Do you have the donor "pink dot" on your drivers license?(Required)
MM slash DD slash YYYY
By typing your full name, you hereby affirm that the above information and values are accurate to the best of your assessment.
Consent