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Affirm Caregiver Training Registration Form
Please answer the following questions so we can register you for the training and be sure to accommodate any childcare and dietary requests.
Email *
Please enter your first and last name here *
Please enter your birthdate (MM/DD/YYYY) *
What is your phone number? *
Are there other caregivers in your home? *
If there are other caregivers, are they also participating in AFFIRM?
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If yes, please list their name(s).
What agency are you affiliated with? *
What training date are you registering for? *
Do you have any dietary restrictions or needs?
Will you need childcare provided during the three training sessions? *
If yes, please list the age(s) here so we can be sure to have enough support.
What pronouns do you use? *
What is your sex assigned at birth? *
What is your gender identity? *
What is your sexual orientation? *
What is your race? (Choose one or more) *
Required
What is your ethnicity? *
What is your religious affiliation? *
Are you currently willing to consider providing care for a lesbian, gay or bisexual youth? *
Are you currently willing to consider providing care for a transgender, nonbinary or gender expansive youth? *
As part of this program, we are asking parents and caregivers to complete voluntary surveys before and after participating in the program, and one three months following. You will receive a $25 Visa gift card for each survey completion, and one additional gift card if you complete all three ($100 in total). In order to receive your gift cards, please provide a mailing address:
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