Momma's Safe Haven Registration Form

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Welcome to the Momma’s Safe Haven Registration Form.
Our mission is to provide safe spaces for individuals to heal from trauma while encouraging self-love, higher education, and self-employment. We strive to serve as a support bridge for families seeking the resources and guidance needed to reach the next level in their lives.

This form gathers the information and permissions required to ensure your safety and meaningful participation in all program activities. Thank you for partnering with us in creating a positive and empowering experience for yourself and those you love..

Join our Family Circle. https://www.mommassafehaven.org/family-circle-membership

Full Name *

Best Contact Phone Number *

Email Address *

Emergency Contact (Name + Phone Number) *

Medical Information (“Please list any medical conditions, allergies, medications, or special accommodations you may need.”) or NA *

Photograph & Media Release

“Do you give Momma’s Safe Haven permission to photograph and record you for program documentation, social media, and promotional materials?”

Yes, I give permission

No, I do not give permission

Behavior Agreement

“I understand and agree that I must follow program rules, show respect to staff and peers, and participate safely in all activities.”

I agree to the behavior expectations

I understand that repeated unsafe behavior may result in dismissal from the program

Consent Signature

“By typing my full name, I confirm that all information provided is accurate and I consent to my participation in Momma’s Safe Haven programs.”

Submit

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