Kuttz Deep – Participant Registration Form
Please fill out the following information to register as a participant in the Kuttz Deep program. Your responses will help us better support you and ensure a positive experience.
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Full Name *
Preferred Name (if different) *
Please provide your preferred name if it differs from your full name.
Pronouns (optional)
Share your pronouns, if you would like to.
Date of Birth *
Phone Number *
Please include your area code.
Email Address *
We will use this to communicate with you.
Current Location (City/State) *
Please specify your current city and state.
Current Justice Status *
Select the option that best describes your current situation.
Release Date (if applicable) *
If you are currently incarcerated, please provide your expected release date.
MM
/
DD
Emergency Contact (Name, Relationship, Phone)
Please provide the name, relationship, and phone number of your emergency contact.
Which areas of support are you most interested in? *
Please select all that apply.
Required
Preferred Days/Times to Meet
Specify the days and times that work best for you.
Do you have any accessibility needs or accommodations? *
Please describe any specific needs or accommodations you require.
Consent & Acknowledgment *
Please confirm your understanding and agreement.
Required
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