Mothers for Justice and Equality Health & Wellness Registration

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Please note that by completing this application, you certify that all of the information provided is true and complete.

As a participant in Mothers for Justice and Equality programming I understand that I must participate in all workshop sessions and agree to abide by the Mothers for Justice and Equality's policies, procedures & Code of Conduct.

This application is property of Mothers for Justice and Equality and inclusive of applicable programming and workshops held by its organization.

Email Address *

Full Name *

Address *

Date of Birth *

YYYY

Contact Number (home, cell, office) *

Select each statement that describes your current income *

I receive SNAP (food stamps) from the Department of Transitional Assistance

I receive TAFDC (cash) from the Department of Transitional Assistance

I do not receive TAFDC or SNAP from the Department of Transitional Assistance

What Workshops Are You Participating In? *

Healthy Relationships

Yoga

Debt to Assets

Mindfulness and Self Care

Planting and Gardening with MJE Youth

Women's History Month virtual celebration

Community Conversations with Aretha

Other:

Required

What do you hope to gain from this workshop?

What other workshops would you be interested in seeing at MJE?

Referred by? *

Are you a former or existing member of Mothers for Justice and Equality? *

Yes

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