Registration: Healthy Relationships for People With Disabilities

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Please fill out our form if you'd like to attend our classes!

Classes are facilitated by Regina Cuddeback (Family and Children's Counseling Services) and Erin Vallely (Access to Independence).

Classes are Mondays from 4:30 - 5:30pm at the Access to Independence Office in Cortland (26 N Main St., Cortland NY), for the following Mondays: March 6th, March 13th, March 20th, March 27th, April 10th, April 17th, April 24th, and May 1st (8 classes total).

Email *

What is your full first and last name? *

If you prefer to go by a different name (such as a nickname or chosen name) please write it here.

What pronouns do you use? (How should people refer to you when they don't use your name?) *

She/Her

He/Him

They/Them

Other:

What do you need from us to be able to participate? This includes accessibility accommodations. *

What is your birthday?

YYYY

Is there anything specific you're hoping to learn from our classes? *

Do you have transportation to get to class? *

Yes, I will drive myself

Yes, someone else will drive me

Yes, I will ride public transportation

Yes, I will walk

No, I need help finding transportation

What is the best way to get in touch with you? *

Phone Call

Please write the email or phone number that you would like us to use to contact you. *

Is there anything else you'd like us to know?

Send me a copy of my responses.

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