SPACE Community & Arts Intake Form 
Our 8 week SPACE Community & Arts program takes place once a week on Tuesdays or Sundays.

Sessions run for 90 min and are a beautiful mix of community connection, art creation and adult mentorship.

Above all,  it's a SPACE where you can talk about stuttering, and stutter while you talk! 

At the end of the 2 month experience, participants will have an opportunity to present to a larger group some of the creative work that they have developed.

Fall Program runs the following dates:

Oct 1 or 6

Oct 8 or 13

Oct 15 or 20

Oct 22 or 27

Oct 29 or Nov 3

Nov 5 or Nov 10

Nov 12 or Nov 17

Nov 19 or Nov 24

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Email *
Participant Full Name  *
Participant preferred name (if different than full name) 
Participant Date of Birth  *
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Participant Pronouns  *
Required
Participant Gender *
Participant Age  *
Participant Grade or school year (if applicable)
Parent/Guardian Full Name (if Participant is under 18)
Contact Phone number  *
Mailing Address (please include apt/unit # if applicable) *
Zip code/ Postal Code *
City, State/Province *
Time Zone  *
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