Mindful Eating for the Beloved Community Application Form

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**Please note you may be wait listed as we are nearing capacity for the program beginning March 3, 2021.**

Untitled Title

Name *

What is your interest in the program? *

Are you part of a faith community, and if so, what is it? *

What do you hope to learn? How do you hope to impact your community?

Pronoun Preference

She/Her

He/His

They/Them

Prefer not to say

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Ethnic Identity

Mailing Address (So we can mail you a copy of the Mindful Eating for the Beloved Community book) *

Please offer a 1 paragraph bio that we can share with other participants. Thank you. *

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