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HSA- "The Power to Change" Registration Form
Spring "24" Session: Beginning June 3, 2024 for four weeks
Weekly on Monday 5:00- 7:00 p.m.
Zoom link to The Power to Change group will be emailed when you complete and submit this registration form
* Indicates required question
Email
*
Your email
Name
*
Your answer
Mailing Address
*
Your answer
ZIP Code
*
Your answer
Are you a survivor of domestic violence/intimate partner violence?
*
Yes
No
What are the preferred pronoun(s) you are addressed by?
*
He/Him
They/Them
She/Her
Prefer Not to Say
Other
Required
What is your current marital status?
*
Choose
Never married
Separated
Widowed
Prefer Not to Say
What is your age?
*
Choose
18-24
25-34
35-44
45-54
65-74
Over 75
80 and over
Prefer Not to Say
What is your race?
*
African-American
Asian
Caucasian
Latinx or Hispanic
Native American
Native Hawaiian or Pacific Islander
Other
Prefer Not to say
Required
How did you hear about us?
*
Your answer
I agree to receive certificate of completion I must attend all four sessions for the duration of 2 hours each session and provide a physical mailing address as certificates will be mailed via USP.
*
Yes
Required
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