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Community Wellness Program Registration Form
Please register to participate in your group! (P
or favor regístrese para su grupo)
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to save your progress.
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* Indicates required question
First Name (Primer Nombre)
*
Your answer
Last Name (Apellido)
*
Your answer
Email (Correo Electronico)
*
Your answer
Age (Edad)
*
Your answer
Gender (G
énero)
*
Female / Femenina
Male / Masculino
Nonbinary / No-binario
Prefer not to say / Prefiero no contestar
Other:
Ethnicity (Etnia)
*
White (Blanco)
Black or African-American (Africano-Americano)
Hispanic/Latino (Hispano/Latino)
Asian (Asiatico)
Native-American (Indigena-Americano)
Zip Code (C
ódigo postal)
*
Your answer
Primary language (Lenguaje primario)
*
English
Español
Other:
Estimated annual household income (Estimado de
ingresos del hogar annual)
*
Less than $30,000 (menos de)
Less than $50,000 (menos de)
Less than $70,000 (menos de)
More than $85,000 (mas de)
I prefer not to say
Phone Number (N
úmero de teléfono)
*
Your answer
Is it okay for a Group Facilitator or MWC staff member to contact you at this number? (
¿Está bien que un facilitador de grupo se comunique con usted a este
n
úmero?)
*
Yes / Sí
No
Other:
Do you prefer call or text message? (Prefiere llamada o mensaje de texto?)
*
Your answer
Emergency Contact Name (
contacto de emergencia)
*
Your answer
Emergency Contact Phone (
Teléfono de contacto de emergencia)
*
Your answer
What group(s) will you be attending? (¿A qué grupo(s) asistirá?)
*
Drumming Circle
Grupo Colibri en Español
Self-Care Group
Mindfulness Group
La Cultura Cura: Art Workshop
Coping Skills Crew
Breathing & Stretching for Beginners
Stronger Together: Bipolar + Depression Group
Open Music Room
Grupo de Educacion - Sabados
Required
I understand that the Community Wellness Program is a safe, confidential and supportive environment where people come to access mental health resources. (
Entiendo que el Programa de Bienestar Comunitario es un lugar seguro, confidencial y de apoyo donde las personas acceden a los recursos de salud mental.)
*
Disagree / No estoy de acuerdo
Agree / Estoy de acuerdo
I understand that my behavior, attitude and participation during group matters and can impact others. (
Entiendo que mi comportamiento, actitud y participación durante el grupo es importante y puede afectar a otros.)
*
Disagree / No estoy de acuerdo
Agree / Estoy de acuerdo
If you would like to receive our MWC mailers please leave your address below (
Si desea recibir nuestros anuncios por correo, por favor deje su dirección)
Your answer
My virtual signature (Mi firma electronica)
*
Your answer
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