Ebony Embrace: GLO Circles for NICU Families - Registration Form
Welcome to Ebony Embrace: GLO Circles for NICU Families, a support community dedicated to Black families navigating the NICU journey. We are here to share, support, and empower each other through this experience. Please fill out this form to register for our 4-week support group sessions. Sessions will start at 2pm pacific standard time zone and will be on zoom or google meet.
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Full Name: *
Contact Number:
Email Address: *
Child's Name (if comfortable sharing):
Child's Birth Date:
 *
Child's Gestation Age at Birth:
 *
Hospital or NICU Location:
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Preferred Start Date:
(Please note we have rolling start dates every month.)  
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How did you hear about Ebony Embrace? *
Required
What are you hoping to gain from joining the Ebony Embrace support group? (Check all that apply) *
Required
Please share any specific topics or questions you would like the support group to address: *
Do you have any specific needs or accommodations we should be aware of to better support your participation?
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I consent to participate in the Ebony Embrace: GLO Circles for NICU Families support group and agree to the group's guidelines for respect, privacy, and support.
 *
Required
I agree to be contacted by the facilitators of Ebony Embrace for coordination and updates regarding the support group sessions.
 *
Required
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